Provider Demographics
NPI:1346562857
Name:KEISE, LYDIA NICOLE (MD)
Entity Type:Individual
Prefix:DR
First Name:LYDIA
Middle Name:NICOLE
Last Name:KEISE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 PLYMOUTH ST
Mailing Address - Street 2:SUITE 108
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-2677
Mailing Address - Country:US
Mailing Address - Phone:973-744-6440
Mailing Address - Fax:
Practice Address - Street 1:33 PLYMOUTH ST
Practice Address - Street 2:SUITE 108
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-2677
Practice Address - Country:US
Practice Address - Phone:973-744-6440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-24
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA087068002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1720367832OtherGROUP NPI
NJ271890426OtherTAX ID