Provider Demographics
NPI:1710059340
Name:PETRAS, LYNN C (PHD)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:C
Last Name:PETRAS
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 1:5701 RILEY RD
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6883
Mailing Address - Country:US
Mailing Address - Phone:423-326-1258
Mailing Address - Fax:
Practice Address - Street 1:5701 RILEY RD
Practice Address - Street 2:
Practice Address - City:OOLTEWAH
Practice Address - State:TN
Practice Address - Zip Code:37363-6883
Practice Address - Country:US
Practice Address - Phone:423-326-1258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP0000001679103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3685432Medicare ID - Type UnspecifiedMEDICARE