Provider Demographics
NPI:1073203311
Name:LYDON, ELIZA BOWEN
Entity type:Individual
Prefix:
First Name:ELIZA
Middle Name:BOWEN
Last Name:LYDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELIZA
Other - Middle Name:GRACE
Other - Last Name:BOWEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 126
Mailing Address - Street 2:
Mailing Address - City:SEALEVEL
Mailing Address - State:NC
Mailing Address - Zip Code:28577-0126
Mailing Address - Country:US
Mailing Address - Phone:252-943-8030
Mailing Address - Fax:
Practice Address - Street 1:4251 ARENDELL ST STE E
Practice Address - Street 2:
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-2871
Practice Address - Country:US
Practice Address - Phone:252-314-9944
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-10
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA18829101YM0800X
NC101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health