Basic Information
| Provider Information | |||||||||
| NPI: | 1386378404 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIDSTON | ||||||||
| FirstName: | ROBIN | ||||||||
| MiddleName: | LOUISE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 781076 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482781076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175284800 | ||||||||
| FaxNumber: | 3178651479 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 45TH ST | ||||||||
| Address2: | |||||||||
| City: | MUNSTER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463212818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1219852251 | ||||||||
| FaxNumber: | 2198522443 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2022 | ||||||||
| LastUpdateDate: | 08/31/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 39002697A | IN | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.