Provider Demographics
NPI:1275051724
Name:PERRY, LYDIA PRUDENCE (LPC, LADC)
Entity Type:Individual
Prefix:MS
First Name:LYDIA
Middle Name:PRUDENCE
Last Name:PERRY
Suffix:
Gender:F
Credentials:LPC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 WATER ST APT 304
Mailing Address - Street 2:
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355-2534
Mailing Address - Country:US
Mailing Address - Phone:860-705-9630
Mailing Address - Fax:
Practice Address - Street 1:1 FORT HILL RD STE 6
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-4799
Practice Address - Country:US
Practice Address - Phone:860-705-9630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-05
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4323101YP2500X
CT1256101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)