Provider Demographics
NPI:1063708543
Name:VINCENT, LYNDON
Entity type:Individual
Prefix:
First Name:LYNDON
Middle Name:
Last Name:VINCENT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GARDNER ST APT 25
Mailing Address - Street 2:
Mailing Address - City:ROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02119-1564
Mailing Address - Country:US
Mailing Address - Phone:617-541-0615
Mailing Address - Fax:
Practice Address - Street 1:434 WARREN ST
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02121-1325
Practice Address - Country:US
Practice Address - Phone:617-541-6859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-23
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health