Healthcare Provider Details

I. General information

NPI: 1578787719
Provider Name (Legal Business Name): MR. JEREMY MICHAEL LYNCH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14701 NATIONAL HWY SW SUITE 5 & 6
LAVALE MD
21502-6573
US

IV. Provider business mailing address

12 S LEE ST APT 5B
CUMBERLAND MD
21502-2801
US

V. Phone/Fax

Practice location:
  • Phone: 301-687-0940
  • Fax: 301-687-0948
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: