Provider Demographics
NPI:1861007387
Name:VINTINNER, LYLE (PSYD)
Entity Type:Individual
Prefix:
First Name:LYLE
Middle Name:
Last Name:VINTINNER
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 1ST ST STE 2
Mailing Address - Street 2:
Mailing Address - City:TOPSHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04086-1334
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:53 BAXTER BLVD STE 3
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-1827
Practice Address - Country:US
Practice Address - Phone:413-356-5423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-11
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1866103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical