Provider Demographics
NPI:1225167869
Name:MOORE, LYDA PARKER (MA)
Entity Type:Individual
Prefix:
First Name:LYDA
Middle Name:PARKER
Last Name:MOORE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 W STEPHEN FOSTER AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-1465
Mailing Address - Country:US
Mailing Address - Phone:502-350-3594
Mailing Address - Fax:502-348-3505
Practice Address - Street 1:120 W STEPHEN FOSTER AVENUE
Practice Address - Street 2:SUITE 101
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-1465
Practice Address - Country:US
Practice Address - Phone:502-350-3594
Practice Address - Fax:502-348-3505
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY401103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY89000020Medicaid
583565Medicare UPIN
KY0700402Medicare ID - Type Unspecified