Healthcare Provider Details

I. General information

NPI: 1578052908
Provider Name (Legal Business Name): LYDIA LIVELY LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LYDIA MEAD LCSW

II. Dates (important events)

Enumeration Date: 05/01/2018
Last Update Date: 10/05/2020
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 MAIN ST STE 2
GREENFIELD MA
01301-3275
US

IV. Provider business mailing address

PO BOX 13
HEATH MA
01346-0013
US

V. Phone/Fax

Practice location:
  • Phone: 413-774-6252
  • Fax: 413-773-0477
Mailing address:
  • Phone: 413-774-0918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number223180
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: