Healthcare Provider Details

I. General information

NPI: 1689097750
Provider Name (Legal Business Name): LYNCIA WRIGHT-WHITE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2014
Last Update Date: 01/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2148 RASPBERRY CT SE APT M
GRAND RAPIDS MI
49546-5973
US

IV. Provider business mailing address

2148 RASPBERRY CT SE APT M
GRAND RAPIDS MI
49546-5973
US

V. Phone/Fax

Practice location:
  • Phone: 616-325-5906
  • Fax:
Mailing address:
  • Phone: 616-325-5906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberW623564676726
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: