Provider Demographics
NPI:1770068314
Name:LYDON, BRIANNE AILEEN (LICSW)
Entity type:Individual
Prefix:
First Name:BRIANNE
Middle Name:AILEEN
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 1:2 PARKER RD
Mailing Address - Street 2:
Mailing Address - City:SHIRLEY
Mailing Address - State:MA
Mailing Address - Zip Code:01464-2122
Mailing Address - Country:US
Mailing Address - Phone:978-609-7701
Mailing Address - Fax:
Practice Address - Street 1:169 ELM ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-5356
Practice Address - Country:US
Practice Address - Phone:781-647-0542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-29
Last Update Date:2018-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1195081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical