Basic Information
| Provider Information | |||||||||
| NPI: | 1871532853 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PERETZ | ||||||||
| FirstName: | LYDIA | ||||||||
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| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 OLD COUNTRY RD | ||||||||
| Address2: | SUITE 271 | ||||||||
| City: | CARLE PLACE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115141801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007256280 | ||||||||
| FaxNumber: | 8007256380 | ||||||||
| Practice Location | |||||||||
| Address1: | 8522 125TH ST | ||||||||
| Address2: | |||||||||
| City: | KEW GARDENS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114153311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184416432 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 013038 | NY | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.