Provider Demographics
NPI:1780187922
Name:LYDON, KATHLEEN (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:
Last Name:LYDON
Suffix:
Gender:F
Credentials:LICSW
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 690267
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02269-0267
Mailing Address - Country:US
Mailing Address - Phone:617-770-4065
Mailing Address - Fax:
Practice Address - Street 1:162 OLD COLONY AVE
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02170-3873
Practice Address - Country:US
Practice Address - Phone:617-770-4065
Practice Address - Fax:617-770-2206
Is Sole Proprietor?:No
Enumeration Date:2018-03-14
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1184851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical