Provider Demographics
NPI:1588766844
Name:HAREN, LYDIA (MD)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:HAREN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 EVATT LN
Mailing Address - Street 2:SUITE 106
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29405-8700
Mailing Address - Country:US
Mailing Address - Phone:843-745-5153
Mailing Address - Fax:
Practice Address - Street 1:2900 EVATT LN
Practice Address - Street 2:SUITE 106
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-8700
Practice Address - Country:US
Practice Address - Phone:843-745-5153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20542103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC205423Medicaid
H64584Medicare UPIN