Provider Demographics
NPI:1902042344
Name:KENIN, LYDIA (PSYD, LICSW)
Entity Type:Individual
Prefix:DR
First Name:LYDIA
Middle Name:
Last Name:KENIN
Suffix:
Gender:F
Credentials:PSYD, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 METACOMET RD
Mailing Address - Street 2:
Mailing Address - City:WABAN
Mailing Address - State:MA
Mailing Address - Zip Code:02468-1418
Mailing Address - Country:US
Mailing Address - Phone:617-969-7393
Mailing Address - Fax:
Practice Address - Street 1:45 METACOMET RD
Practice Address - Street 2:
Practice Address - City:WABAN
Practice Address - State:MA
Practice Address - Zip Code:02468-1418
Practice Address - Country:US
Practice Address - Phone:617-969-7393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-06
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4186103T00000X
MA1039301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW50166OtherMEDICARE PARTICIPATING SUPPLIER IDENTIFICATION CODE
MAWO5557OtherBLUE CROSS BLUE SHIELD