Provider Demographics
NPI:1356469290
Name:LIDKEA, MARY (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:LIDKEA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1362
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32790-1362
Mailing Address - Country:US
Mailing Address - Phone:407-628-5122
Mailing Address - Fax:
Practice Address - Street 1:2221 LEE RD
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-1864
Practice Address - Country:US
Practice Address - Phone:407-628-5122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY3664103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75967Medicare ID - Type Unspecified