Provider Demographics
NPI:1851769798
Name:MCMILLEN DICKEYTESDALL, LYNAE
Entity Type:Individual
Prefix:
First Name:LYNAE
Middle Name:
Last Name:MCMILLEN DICKEYTESDALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 19TH ST
Mailing Address - Street 2:PO BOX 70
Mailing Address - City:ROCK VALLEY
Mailing Address - State:IA
Mailing Address - Zip Code:51247-1058
Mailing Address - Country:US
Mailing Address - Phone:712-476-3281
Mailing Address - Fax:712-476-2970
Practice Address - Street 1:1800 19TH ST
Practice Address - Street 2:
Practice Address - City:ROCK VALLEY
Practice Address - State:IA
Practice Address - Zip Code:51247-1058
Practice Address - Country:US
Practice Address - Phone:712-476-3281
Practice Address - Fax:712-476-2970
Is Sole Proprietor?:No
Enumeration Date:2015-09-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA074799101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health