Provider Demographics
NPI:1477146710
Name:LYDSTON, CHERYL LYNN (LISW - S)
Entity Type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:LYNN
Last Name:LYDSTON
Suffix:
Gender:F
Credentials:LISW - S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13901 GROVE DR
Mailing Address - Street 2:
Mailing Address - City:GARFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44125-5207
Mailing Address - Country:US
Mailing Address - Phone:216-402-1876
Mailing Address - Fax:
Practice Address - Street 1:2554 WEST 25TH STREET
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44113
Practice Address - Country:US
Practice Address - Phone:216-781-2250
Practice Address - Fax:216-781-2252
Is Sole Proprietor?:No
Enumeration Date:2021-02-18
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.0700334-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical