Provider Demographics
NPI:1407221211
Name:AVERILL, LYNNETTE A (PHD)
Entity Type:Individual
Prefix:DR
First Name:LYNNETTE
Middle Name:A
Last Name:AVERILL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3520 N UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-6648
Mailing Address - Country:US
Mailing Address - Phone:801-787-9855
Mailing Address - Fax:
Practice Address - Street 1:3520 N UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-6648
Practice Address - Country:US
Practice Address - Phone:801-787-9855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-04
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9385148-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical