MEDICARE: PETER JOSEPH LYDON 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	21923	CA

General Provider Information

NPI Number	:	1427159607
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETER JOSEPH LYDON LCSW

Provider Business Mailing Address
First Line	:	5710 E 7TH ST
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90803-2002
Country	:	US
Telephone Number	:	562-826-8000
Fax Number	:

Provider Business Practice Location Address
First Line	:	5710 E 7TH ST
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90803-2002
Country	:	US
Telephone Number	:	562-826-8000
Fax Number	:

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

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	07/08/2007

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