Provider Demographics
NPI:1508380270
Name:PETERS, LYDIA
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:PETERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 PINE STREET
Mailing Address - Street 2:2W
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12207
Mailing Address - Country:US
Mailing Address - Phone:347-623-4908
Mailing Address - Fax:
Practice Address - Street 1:130 W KINGSBRIDGE RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-3904
Practice Address - Country:US
Practice Address - Phone:347-623-4908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-03
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY094828104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker