Provider Demographics
NPI:1861843971
Name:CLYDE, LYNNE (LMFT, #104574)
Entity Type:Individual
Prefix:
First Name:LYNNE
Middle Name:
Last Name:CLYDE
Suffix:
Gender:F
Credentials:LMFT, #104574
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 N REDWOOD DR STE 225
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-1980
Mailing Address - Country:US
Mailing Address - Phone:415-462-4399
Mailing Address - Fax:
Practice Address - Street 1:185 N REDWOOD DR STE 225
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903
Practice Address - Country:US
Practice Address - Phone:415-462-4399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-29
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104574106H00000X
CA93178106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist