Basic Information
| Provider Information | |||||||||
| NPI: | 1982623559 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LYNE | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4024 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337111239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273277656 | ||||||||
| FaxNumber: | 7273222103 | ||||||||
| Practice Location | |||||||||
| Address1: | 4024 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337111239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273277656 | ||||||||
| FaxNumber: | 7273222103 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 08/03/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 14478 | MN | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 152217 | 01 | MN | BEHAVIORAL HEALTHCARE | OTHER | 62-68816 | 01 | MN | UNITED BEHAVIORAL HEALTH | OTHER | 400057900 | 05 | MN | MEDICAID |