Healthcare Provider Details

I. General information

NPI: 1003901000
Provider Name (Legal Business Name): ROSS LYLE FLYNN PHD, LPC, LMFT, NCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 06/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 WALNUT BLVD SUITE 109
ROCHESTER MI
48307-2073
US

IV. Provider business mailing address

71 WALNUT BLVD SUITE 109
ROCHESTER MI
48307-2073
US

V. Phone/Fax

Practice location:
  • Phone: 586-242-5512
  • Fax:
Mailing address:
  • Phone: 586-242-5512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401007374
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number4101006255
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: