MEDICARE: MS. MARGARET RAY LIDSTROM LCSW

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	0904000638	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	O84350	OTHER	VA	OPTIMA HEALTH CARE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	140254	OTHER	VA	ANTHEM BCBS

General Provider Information

NPI Number	:	1053351387
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARGARET RAY LIDSTROM LCSW

Provider Business Mailing Address
First Line	:	2940 N LYNNHAVEN RD
Second Line	:	SUITE 130
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23452-6949
Country	:	US
Telephone Number	:	757-636-9187
Fax Number	:	888-785-9387

Provider Business Practice Location Address
First Line	:	2940 N LYNNHAVEN RD
Second Line	:	SUITE 130
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23452-6949
Country	:	US
Telephone Number	:	757-636-9187
Fax Number	:	888-785-9387

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2006
Last Update Date	:	12/09/2016

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