Provider Demographics
NPI:1316904956
Name:LYDIA HOME ASSOCIATION
Entity type:Organization
Organization Name:LYDIA HOME ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:K
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PSY D
Authorized Official - Phone:773-736-1447
Mailing Address - Street 1:4300 W IRVING PARK RD
Mailing Address - Street 2:COUNSELING CENTER
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-2825
Mailing Address - Country:US
Mailing Address - Phone:773-736-1447
Mailing Address - Fax:773-736-6970
Practice Address - Street 1:4300 W IRVING PARK RD #B
Practice Address - Street 2:COUNSELING CENTER
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-2825
Practice Address - Country:US
Practice Address - Phone:773-736-1447
Practice Address - Fax:773-736-6970
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X, 103TC0700X, 103TC1900X, 103TC2200X, 103TP2701X, 1041C0700X, 106H00000X, 104100000X
251B00000X, 251S00000X, 261QM0855X, 261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Not Answered104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILPENDINGMedicare ID - Type UnspecifiedIN PROCESS OF APPLICATION