Healthcare Provider Details

I. General information

NPI: 1477267383
Provider Name (Legal Business Name): MADDISON N TOLLIVER-LYNN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MADDISON LYNN

II. Dates (important events)

Enumeration Date: 01/06/2023
Last Update Date: 01/27/2023
Certification Date: 01/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 WISHARD BLVD STE 4110
INDIANAPOLIS IN
46202-4164
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-944-8162
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20043618A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: