Lynn Supple, PSYD

Key facts

NPI

1093173239

Entity type

Individual (NPI type 1)

Primary specialty

Clinical Psychologist 103TC0700X

License

075591 (IA)

Practice address

16 N Gore Ave
Suite 203
Saint Louis, MO 63119-2315

Phone

(615) 574-5957

NPI assigned

Feb 2, 2016

Sex

Female

Sole proprietor

Yes

Organizations & group practices 1

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Aspire Wellness, LLC Adolescent and Children Mental Health Clinic/Center · Louisville, KY · NPI 1730841859
  NPD Authorized official

Medicare participation

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

National Provider Directory

Medicare enrollment (NPD)

No

State licenses

Practice roles

Specialties & licenses

Addresses

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Feb 2, 2016.

{
    "created_epoch": "1454371200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1454371200000",
    "number": "1093173239",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1103 SELMA AVE",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631194766",
            "telephone_number": "615-574-5957"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "16 N GORE AVE",
            "address_2": "SUITE 203",
            "city": "SAINT LOUIS",
            "state": "MO",
            "postal_code": "631192315",
            "telephone_number": "615-574-5957"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SUPPLE",
        "first_name": "LYNN",
        "name_prefix": "Dr.",
        "credential": "PSYD",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2016-02-02",
        "last_updated": "2016-02-02",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "IA",
            "license": "075591",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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