Provider Demographics
NPI:1548425655
Name:LYNCH, MALLORY BRETT (PHD)
Entity Type:Individual
Prefix:MR
First Name:MALLORY
Middle Name:BRETT
Last Name:LYNCH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1268 SUNCREST RD
Mailing Address - Street 2:
Mailing Address - City:TALENT
Mailing Address - State:OR
Mailing Address - Zip Code:97540-9642
Mailing Address - Country:US
Mailing Address - Phone:541-535-4812
Mailing Address - Fax:
Practice Address - Street 1:1268 SUNCREST RD
Practice Address - Street 2:
Practice Address - City:TALENT
Practice Address - State:OR
Practice Address - Zip Code:97540-9642
Practice Address - Country:US
Practice Address - Phone:541-535-4812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-29
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0365103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist