Provider Demographics
NPI:1164827655
Name:WIEDE, LYDIA (PHD, LCPC)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:WIEDE
Suffix:
Gender:F
Credentials:PHD, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 S ILLINOIS AVE
Mailing Address - Street 2:
Mailing Address - City:VILLA PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60181-2959
Mailing Address - Country:US
Mailing Address - Phone:630-247-5478
Mailing Address - Fax:
Practice Address - Street 1:441 S ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:VILLA PARK
Practice Address - State:IL
Practice Address - Zip Code:60181-2959
Practice Address - Country:US
Practice Address - Phone:630-247-5478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-27
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.009004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health