Provider Demographics
NPI:1679788616
Name:STATEN, LYDIA M (LCSW)
Entity type:Individual
Prefix:MRS
First Name:LYDIA
Middle Name:M
Last Name:STATEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:LYDIA
Other - Middle Name:ELEANOR
Other - Last Name:MILLWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1820 HIGHWAY 80 WEST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-2056
Mailing Address - Country:US
Mailing Address - Phone:601-540-7105
Mailing Address - Fax:
Practice Address - Street 1:1225 N WEST ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2056
Practice Address - Country:US
Practice Address - Phone:601-540-7105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-12
Last Update Date:2012-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC0715101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00120550Medicaid