Provider Demographics
NPI:1487395562
Name:LYNCH, MARANDA LYNN
Entity type:Individual
Prefix:
First Name:MARANDA
Middle Name:LYNN
Last Name:LYNCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12262 SHADY SPRING WAY
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-9168
Mailing Address - Country:US
Mailing Address - Phone:321-400-4605
Mailing Address - Fax:
Practice Address - Street 1:467 LAKE HOWELL RD
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-5922
Practice Address - Country:US
Practice Address - Phone:407-499-2813
Practice Address - Fax:407-386-6897
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician