Healthcare Provider Details

I. General information

NPI: 1043239676
Provider Name (Legal Business Name): KERRY WAYNE LYNCH PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8380 NORTH ST.
IXONIA WI
53036
US

IV. Provider business mailing address

5000 W NATIONAL AVE
MILWAUKEE WI
53295-0001
US

V. Phone/Fax

Practice location:
  • Phone: 262-569-0811
  • Fax:
Mailing address:
  • Phone: 414-384-2000
  • Fax: 414-382-5298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number1458057
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: