Provider Demographics
NPI:1710087663
Name:QUACKENBUSH, LYNN A (LCSW)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:A
Last Name:QUACKENBUSH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12301 S MAIN ST
Mailing Address - Street 2:THE MENNINGER CLINIC
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77035-6207
Mailing Address - Country:US
Mailing Address - Phone:713-275-5000
Mailing Address - Fax:207-973-6109
Practice Address - Street 1:268 STILLWATER AVE
Practice Address - Street 2:ACADIA HOSPITAL CORP.
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3945
Practice Address - Country:US
Practice Address - Phone:207-973-6100
Practice Address - Fax:207-973-6109
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC70041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME104000000Medicaid
ME093351Medicare ID - Type Unspecified