Basic Information
Provider Information | |||||||||
NPI: | 1770766438 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KNAPP | ||||||||
FirstName: | LYNETTE | ||||||||
MiddleName: | K | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | VA POLO ALTO HEALTH CARE SYSTEM MENLO PARK DIVISION | ||||||||
Address2: | 795 WILLOW ROAD | ||||||||
City: | MENLO PARK | ||||||||
State: | CA | ||||||||
PostalCode: | 94025 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6504935000 | ||||||||
FaxNumber: | 6506172624 | ||||||||
Practice Location | |||||||||
Address1: | 230 E MARYDALE AVE | ||||||||
Address2: |   | ||||||||
City: | SOLDOTNA | ||||||||
State: | AK | ||||||||
PostalCode: | 996697648 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9072623119 | ||||||||
FaxNumber: | 9072627301 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/17/2007 | ||||||||
LastUpdateDate: | 05/10/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/10/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 1179 | AK | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 6801069253 | MI | N |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | CSWS1179 | AK | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.