Provider Demographics
NPI:1578019113
Name:LYDIA WARD-GRAY, PSYD, LLC
Entity Type:Organization
Organization Name:LYDIA WARD-GRAY, PSYD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WARD-GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:207-232-4508
Mailing Address - Street 1:19 SOUTH ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-3963
Mailing Address - Country:US
Mailing Address - Phone:207-232-4508
Mailing Address - Fax:
Practice Address - Street 1:19 SOUTH STREET
Practice Address - Street 2:SUITE 4
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101
Practice Address - Country:US
Practice Address - Phone:207-232-4508
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS881103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty