Provider Demographics
NPI:1316499767
Name:BYUN, LYDIA (ATR)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:BYUN
Suffix:
Gender:F
Credentials:ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 MESEROLE ST
Mailing Address - Street 2:APT 1B
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206-2397
Mailing Address - Country:US
Mailing Address - Phone:973-600-9013
Mailing Address - Fax:
Practice Address - Street 1:3708 91ST ST
Practice Address - Street 2:SUITE 3A
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7961
Practice Address - Country:US
Practice Address - Phone:718-779-2263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-02
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002043101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJLJ721666467OtherEMPIRE BLUE CROSS BLUE SHIELD NY ESSENTIAL PLAN