Provider Demographics
NPI:1932111994
Name:SHAMBLIN, LYDA (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:LYDA
Middle Name:
Last Name:SHAMBLIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 S SMALL AVE
Mailing Address - Street 2:
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-3252
Mailing Address - Country:US
Mailing Address - Phone:815-932-4700
Mailing Address - Fax:815-932-5734
Practice Address - Street 1:410 S SMALL AVE
Practice Address - Street 2:
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-3252
Practice Address - Country:US
Practice Address - Phone:815-932-4700
Practice Address - Fax:815-932-5734
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490018961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical