Healthcare Provider Details

I. General information

NPI: 1588766844
Provider Name (Legal Business Name): LYDIA HAREN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 EVATT LN SUITE 106
CHARLESTON SC
29405-8700
US

IV. Provider business mailing address

2900 EVATT LN SUITE 106
CHARLESTON SC
29405-8700
US

V. Phone/Fax

Practice location:
  • Phone: 843-745-5153
  • Fax:
Mailing address:
  • Phone: 843-745-5153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number20542
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: