MEDICARE: DR. LISA TYNDALL PH.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1932310323
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA TYNDALL PH.D

Provider Business Mailing Address
First Line	:	612 E 10TH ST
Second Line	:	ECU FAMILY THERAPY CLINIC
City	:	GREENVILLE
State	:	NC
Zip	:	27858-3411
Country	:	US
Telephone Number	:	252-737-1415
Fax Number	:

Provider Business Practice Location Address
First Line	:	612 E 10TH ST
Second Line	:	ECU FAMILY THERAPY CLINIC
City	:	GREENVILLE
State	:	NC
Zip	:	27858-3411
Country	:	US
Telephone Number	:	252-737-1415
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/25/2007
Last Update Date	:	08/23/2010

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