Provider Demographics
NPI:1710117536
Name:ELISON, LYDIA ROSE (MD)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:ROSE
Last Name:ELISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:30 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060-2052
Mailing Address - Country:US
Mailing Address - Phone:413-582-2151
Mailing Address - Fax:413-582-2838
Practice Address - Street 1:30 LOCUST ST
Practice Address - Street 2:
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-2052
Practice Address - Country:US
Practice Address - Phone:413-582-2151
Practice Address - Fax:413-582-2838
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-15
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA2402272084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS400193759Medicare UPIN
MAS400182456Medicare UPIN