Provider Demographics
NPI:1063032324
Name:BLACKWOOD-ELLIS, LYDIA ISABELLE (PHD)
Entity Type:Individual
Prefix:DR
First Name:LYDIA
Middle Name:ISABELLE
Last Name:BLACKWOOD-ELLIS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7826 EASTERN AVE NW STE 325
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20012-1334
Mailing Address - Country:US
Mailing Address - Phone:202-726-6062
Mailing Address - Fax:302-726-0032
Practice Address - Street 1:7826 EASTERN AVE NW STE 325
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20012-1334
Practice Address - Country:US
Practice Address - Phone:202-726-6062
Practice Address - Fax:202-726-0032
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-16
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC01445103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical