Provider Demographics
NPI:1861617151
Name:LYDER, DONNA F (PMH, CNS-BC)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:F
Last Name:LYDER
Suffix:
Gender:F
Credentials:PMH, CNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 HARVARD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-6429
Mailing Address - Country:US
Mailing Address - Phone:617-232-4570
Mailing Address - Fax:617-232-4585
Practice Address - Street 1:131 HARVARD ST
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-6429
Practice Address - Country:US
Practice Address - Phone:617-232-4570
Practice Address - Fax:617-232-4585
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA217927163WP0808X
MARN217927364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health