Provider Demographics
NPI:1437749017
Name:WRISTON, LYNDSI O
Entity Type:Individual
Prefix:
First Name:LYNDSI
Middle Name:O
Last Name:WRISTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 FAYETTE AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25840-1219
Mailing Address - Country:US
Mailing Address - Phone:304-574-1176
Mailing Address - Fax:
Practice Address - Street 1:111 FAYETTE AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:WV
Practice Address - Zip Code:25840-1219
Practice Address - Country:US
Practice Address - Phone:304-574-1176
Practice Address - Fax:304-574-4109
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-2102235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist