Provider Demographics
NPI:1932303005
Name:LYNN, KATHLEEN M (MSW, BCD)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:M
Last Name:LYNN
Suffix:
Gender:F
Credentials:MSW, BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4467 CASCADE RD. SE
Mailing Address - Street 2:SUITE 4469
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546
Mailing Address - Country:US
Mailing Address - Phone:616-940-3331
Mailing Address - Fax:616-940-0712
Practice Address - Street 1:4467 CASCADE RD. SE
Practice Address - Street 2:SUITE 4469
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546
Practice Address - Country:US
Practice Address - Phone:616-940-3331
Practice Address - Fax:616-940-0712
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0117391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0890678Medicare PIN