Provider Demographics
NPI:1053351387
Name:LIDSTROM, MARGARET RAY (LCSW)
Entity type:Individual
Prefix:MS
First Name:MARGARET
Middle Name:RAY
Last Name:LIDSTROM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2940 N LYNNHAVEN RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-6949
Mailing Address - Country:US
Mailing Address - Phone:757-636-9187
Mailing Address - Fax:888-785-9387
Practice Address - Street 1:2940 N LYNNHAVEN RD
Practice Address - Street 2:SUITE 130
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-6949
Practice Address - Country:US
Practice Address - Phone:757-636-9187
Practice Address - Fax:888-785-9387
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040006381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAO84350OtherOPTIMA HEALTH CARE
VA008928096Medicaid
VA140254OtherANTHEM BCBS
VA008928096Medicaid
VAQ4725C603Medicare PIN