Provider Demographics
NPI:1194080622
Name:LYDE, MIRIAM REISHUN (LCMHC,LCAS-P)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:REISHUN
Last Name:LYDE
Suffix:
Gender:F
Credentials:LCMHC,LCAS-P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-718-3550
Mailing Address - Fax:336-277-6981
Practice Address - Street 1:820 GRIMES BLVD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:NC
Practice Address - Zip Code:27292-7640
Practice Address - Country:US
Practice Address - Phone:336-224-6071
Practice Address - Fax:336-224-6393
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLPCA11494101YP2500X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional