Provider Demographics
NPI:1538470463
Name:ALLISON, LYDIA (MSW)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:ALLISON
Suffix:
Gender:F
Credentials:MSW
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 59
Mailing Address - Street 2:
Mailing Address - City:KINGDOM CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65262-0059
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8548 JADE ROAD
Practice Address - Street 2:
Practice Address - City:KINGDOM CITY
Practice Address - State:MO
Practice Address - Zip Code:65262
Practice Address - Country:US
Practice Address - Phone:573-642-5345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-25
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1780821850Medicaid