Provider Demographics
NPI:1750857314
Name:LYNCH, LESLIE NICOLE (BCBA)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:NICOLE
Last Name:LYNCH
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5556 N MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-2658
Mailing Address - Country:US
Mailing Address - Phone:317-334-7331
Mailing Address - Fax:317-334-7336
Practice Address - Street 1:8646 GUION RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-3011
Practice Address - Country:US
Practice Address - Phone:317-334-7331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-22
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-18-31988103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300020337Medicaid