Provider Demographics
NPI:1922101187
Name:MOREST, LYDIA ROSE (LICSW)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:ROSE
Last Name:MOREST
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:LYDIA
Other - Middle Name:MOREST
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:22 MILL ST
Mailing Address - Street 2:SUITE 407
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02476-4784
Mailing Address - Country:US
Mailing Address - Phone:617-794-0940
Mailing Address - Fax:
Practice Address - Street 1:22 MILL ST
Practice Address - Street 2:SUITE 407
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02476-4784
Practice Address - Country:US
Practice Address - Phone:617-794-0940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1155831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1852302Medicaid
MA1852302Medicaid