Provider Demographics
NPI:1417901083
Name:LYNNE, WILLIAM STUART (LPP)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:STUART
Last Name:LYNNE
Suffix:
Gender:M
Credentials:LPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1643 N FORT THOMAS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT THOMAS
Mailing Address - State:KY
Mailing Address - Zip Code:41075-1118
Mailing Address - Country:US
Mailing Address - Phone:859-816-4279
Mailing Address - Fax:
Practice Address - Street 1:18 N FORT THOMAS AVE
Practice Address - Street 2:
Practice Address - City:FORT THOMAS
Practice Address - State:KY
Practice Address - Zip Code:41075-3098
Practice Address - Country:US
Practice Address - Phone:859-816-4279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0023103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY184607OtherMEDICARE GROUP NUMBER
KY610661458OtherFEDERAL TAX ID NUMBER