Provider Demographics
NPI:1518387844
Name:LYDIC, ANNAMARIE NICOLE (LCSW)
Entity type:Individual
Prefix:
First Name:ANNAMARIE
Middle Name:NICOLE
Last Name:LYDIC
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 1:1450 YANKEE HILL RD
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15717-5158
Mailing Address - Country:US
Mailing Address - Phone:724-840-6144
Mailing Address - Fax:
Practice Address - Street 1:1450 YANKEE HILL RD
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15717-5158
Practice Address - Country:US
Practice Address - Phone:724-840-6144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-25
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 104100000X
PACW0199341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No104100000XBehavioral Health & Social Service ProvidersSocial Worker