Provider Demographics
NPI:1609355163
Name:LYN-LAKE PSYCHOTHERAPY AND WELLNESS LTD.
Entity Type:Organization
Organization Name:LYN-LAKE PSYCHOTHERAPY AND WELLNESS LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:VAN WYK
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD, LP
Authorized Official - Phone:651-485-8417
Mailing Address - Street 1:621 W LAKE ST STE 350
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-2952
Mailing Address - Country:US
Mailing Address - Phone:612-979-2276
Mailing Address - Fax:651-925-0427
Practice Address - Street 1:621 W LAKE ST STE 350
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2952
Practice Address - Country:US
Practice Address - Phone:612-979-2276
Practice Address - Fax:651-925-0427
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-07
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC0700X
MN00463101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty