Provider Demographics
NPI:1962848804
Name:LYN, MARI (LPCC)
Entity Type:Individual
Prefix:
First Name:MARI
Middle Name:
Last Name:LYN
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:LYN
Other - Last Name:BALLENTINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:625 CLEVELAND AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44702-1805
Mailing Address - Country:US
Mailing Address - Phone:330-455-0374
Mailing Address - Fax:330-455-2101
Practice Address - Street 1:1711 SPRING AVE NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44714-2349
Practice Address - Country:US
Practice Address - Phone:330-454-6800
Practice Address - Fax:330-588-7176
Is Sole Proprietor?:No
Enumeration Date:2013-05-20
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.1300345101YP2500X, 101YP2500X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0181586Medicaid