MEDICARE: LYDIA BETH STANTON 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	LCS20525	CA

General Provider Information

NPI Number	:	1770676769
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYDIA BETH STANTON LCSW

Provider Business Mailing Address
First Line	:	3435 CAMINO DEL RIO S
Second Line	:	STE 123
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-3910
Country	:	US
Telephone Number	:	619-980-3396
Fax Number	:	619-574-8515

Provider Business Practice Location Address
First Line	:	3435 CAMINO DEL RIO S
Second Line	:	STE 123
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-3910
Country	:	US
Telephone Number	:	619-980-3396
Fax Number	:	619-574-8515

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

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	11/08/2017

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