Provider Demographics
NPI:1346679404
Name:LYDDANE, MOLLIE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MOLLIE
Middle Name:
Last Name:LYDDANE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 BAYSIDE CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94804-7441
Mailing Address - Country:US
Mailing Address - Phone:281-793-1084
Mailing Address - Fax:
Practice Address - Street 1:2 BAYSIDE CT
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94804-7441
Practice Address - Country:US
Practice Address - Phone:281-793-1084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-08
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 24783103T00000X, 103TA0700X, 103TC0700X, 103TE1100X, 103TH0004X, 103TH0100X, 103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & Sports
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation