Basic Information
Provider Information | |||||||||
NPI: | 1053635540 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILLIAMS | ||||||||
FirstName: | CYNTHIA | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | FANCHER | ||||||||
OtherFirstName: | CYNTHIA | ||||||||
OtherMiddleName: | LYNN | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 660 MORTHLAND DR STE D | ||||||||
Address2: |   | ||||||||
City: | VALPARAISO | ||||||||
State: | IN | ||||||||
PostalCode: | 463854638 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2194629200 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 660 MORTHLAND DR STE D | ||||||||
Address2: |   | ||||||||
City: | VALPARAISO | ||||||||
State: | IN | ||||||||
PostalCode: | 463854638 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2194629200 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/26/2010 | ||||||||
LastUpdateDate: | 01/12/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/12/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 39003313A | IN | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.