Provider Demographics
NPI:1053802686
Name:HARRELSON, LYN DEE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:LYN
Middle Name:DEE
Last Name:HARRELSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16457 GLEDHILL ST
Mailing Address - Street 2:
Mailing Address - City:NORTH HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91343-2845
Mailing Address - Country:US
Mailing Address - Phone:818-808-9809
Mailing Address - Fax:
Practice Address - Street 1:16457 GLEDHILL ST
Practice Address - Street 2:
Practice Address - City:NORTH HILLS
Practice Address - State:CA
Practice Address - Zip Code:91343-2845
Practice Address - Country:US
Practice Address - Phone:818-808-9809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP10763235Z00000X
CA14398235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
12064444OtherAMERICAN SPEECH-LANGUAGE HEARING ASSOCIATION LICENSE #
CA14398OtherLICENSE TO PRACTICE SPEECH LANGUAGE PATHOLOGY