Healthcare Provider Details

I. General information

NPI: 1710117536
Provider Name (Legal Business Name): LYDIA ROSE ELISON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2009
Last Update Date: 03/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 LOCUST ST
NORTHAMPTON MA
01060-2052
US

IV. Provider business mailing address

30 LOCUST ST
NORTHAMPTON MA
01060-2052
US

V. Phone/Fax

Practice location:
  • Phone: 413-582-2151
  • Fax: 413-582-2838
Mailing address:
  • Phone: 413-582-2151
  • Fax: 413-582-2838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number240227
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: