Healthcare Provider Details

I. General information

NPI: 1154578938
Provider Name (Legal Business Name): LYNDA KRISTEN VATERLAUS PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2008
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2617 W BURGESS LN
PHOENIX AZ
85041-5384
US

IV. Provider business mailing address

2617 W BURGESS LN
PHOENIX AZ
85041-5384
US

V. Phone/Fax

Practice location:
  • Phone: 480-779-8181
  • Fax: 480-660-5381
Mailing address:
  • Phone: 480-779-8181
  • Fax: 480-660-5381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY-004161
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY-004161
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License NumberPSY-004161
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: