Provider Demographics
NPI:1700071230
Name:LYNN, HENRY FAIRFAX III (MS, EDS)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:FAIRFAX
Last Name:LYNN
Suffix:III
Gender:M
Credentials:MS, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 RUSH NO MORE LN
Mailing Address - Street 2:
Mailing Address - City:BERKELEY SPRINGS
Mailing Address - State:WV
Mailing Address - Zip Code:25411-6980
Mailing Address - Country:US
Mailing Address - Phone:304-279-8787
Mailing Address - Fax:
Practice Address - Street 1:36 RUSH NO MORE LN
Practice Address - Street 2:
Practice Address - City:BERKELEY SPRINGS
Practice Address - State:WV
Practice Address - Zip Code:25411-6980
Practice Address - Country:US
Practice Address - Phone:304-279-8787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-07
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20024103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0163812000Medicaid