Provider Demographics
NPI:1114988300
Name:REYNOLDS, LYDIA J (MSW, LCSW)
Entity Type:Individual
Prefix:MS
First Name:LYDIA
Middle Name:J
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 LEE AVE
Mailing Address - Street 2:
Mailing Address - City:WHITEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28472-8911
Mailing Address - Country:US
Mailing Address - Phone:910-640-2724
Mailing Address - Fax:910-640-3474
Practice Address - Street 1:26 LEE AVE
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472-8911
Practice Address - Country:US
Practice Address - Phone:910-640-2724
Practice Address - Fax:910-640-3474
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY063636104100000X
NCC0083011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00030241501OtherUNIVERA
NC1114988300Medicaid