MEDICARE: LYDIA HOME ASSOCIATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	101YM0800X	Mental Health Counselor	IL
2	103TC0700X	Clinical Psychologist	IL
3	103TC1900X	Counseling Psychologist	IL
4	103TC2200X	Clinical Child & Adolescent Psychologist	IL
5	251B00000X	Case Management Agency
6	251S00000X	Community/Behavioral Health Agency
7	261QM0855X	Adolescent and Children Mental Health Clinic/Center
8	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1316904956
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LYDIA HOME ASSOCIATION

Provider Business Mailing Address
First Line	:	4300 W IRVING PARK RD
Second Line	:	COUNSELING CENTER
City	:	CHICAGO
State	:	IL
Zip	:	60641-2825
Country	:	US
Telephone Number	:	773-736-1447
Fax Number	:	773-736-6970

Provider Business Practice Location Address
First Line	:	4300 W IRVING PARK RD #B
Second Line	:	COUNSELING CENTER
City	:	CHICAGO
State	:	IL
Zip	:	60641-2825
Country	:	US
Telephone Number	:	773-736-1447
Fax Number	:	773-736-6970

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	DR. DAVID K. ANDERSON
Credential	:	PSY D
Telephone Number	:	773-736-1447

Provider Enumeration Date	:	04/27/2006
Last Update Date	:	02/25/2022

Similar Medicare Providers

1346208410 — ALLAN T. PETERSON PSY. D, MDIV
Practice Location Address:

4300 W IRVING PARK RD , COUNSELING CENTER
CHICAGO, IL
60641-2825

Practice Phone: 773-736-1447
Practice Fax: 773-736-6970

1235197583 — LYDIA HOME ASSOCIATION
Practice Location Address:

4300 W IRVING PARK RD
CHICAGO, IL
60641-2825

Practice Phone: 773-736-1447
Practice Fax: 773-736-5014

1225234297 — MR. ALBERT WOLFE LASER LCPC
Practice Location Address:

LYDIA HOME ASSOCIATION , 4300 W IRVING PARK RD
CHICAGO, IL
60641-2825

Practice Phone: 773-736-1447
Practice Fax: 773-736-6970

1689871345 — DR. DAVID KARL ANDERSON PSY.D.
Practice Location Address:

4300 W IRVING PARK RD
CHICAGO, IL
60641-2825

Practice Phone: 773-736-1447
Practice Fax: 773-736-6970

1285832998 — MRS. PATRICIA JANE UTIGARD MSW
Practice Location Address:

4300 W IRVING PARK RD
CHICAGO, IL
60641-2825

Practice Phone: 773-736-1447
Practice Fax: 773-736-5014

1477752384 — LYNWOOD WAYNE MORRISS
Practice Location Address:

4300 W IRVING PARK RD
CHICAGO, IL
60641-2825

Practice Phone: 773-336-1447
Practice Fax: 773-736-5014

Directions to “LYDIA HOME ASSOCIATION ” Practice Location

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