Provider Demographics
NPI:1467127407
Name:SUNDERLAND, LIDA MARY (ATR-BC, LPC, LCPAT)
Entity Type:Individual
Prefix:
First Name:LIDA
Middle Name:MARY
Last Name:SUNDERLAND
Suffix:
Gender:F
Credentials:ATR-BC, LPC, LCPAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5039 CONNECTICUT AVE NW STE 7
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20008-2056
Mailing Address - Country:US
Mailing Address - Phone:202-660-1422
Mailing Address - Fax:
Practice Address - Street 1:5039 CONNECTICUT AVE NW STE 7
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20008-2056
Practice Address - Country:US
Practice Address - Phone:202-660-1422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-11
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDATC282221700000X
DCPRC15485101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt TherapistGroup - Multi-Specialty