Basic Information
| Provider Information | |||||||||
| NPI: | 1053813493 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LYNN | ||||||||
| FirstName: | NOELLE | ||||||||
| MiddleName: | |||||||||
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| OtherLastName: | GORNIK | ||||||||
| OtherFirstName: | NOELLE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1040 LAFAYETTE AVE SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495071107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162504360 | ||||||||
| FaxNumber: | 6162450450 | ||||||||
| Practice Location | |||||||||
| Address1: | 2025 E BELTLINE AVE SE STE 301 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495467634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162504360 | ||||||||
| FaxNumber: | 6162582214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2018 | ||||||||
| LastUpdateDate: | 01/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N894410 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.