Provider Demographics
NPI:1053063586
Name:ANTHONY, LYDIA MARIE
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:MARIE
Last Name:ANTHONY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LYDIA
Other - Middle Name:MARIE
Other - Last Name:COLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2728 WOODBERRY WAY APT 201
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-4776
Mailing Address - Country:US
Mailing Address - Phone:316-708-2185
Mailing Address - Fax:
Practice Address - Street 1:10670 WHITE ROCK RD STE 150
Practice Address - Street 2:
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95670-6156
Practice Address - Country:US
Practice Address - Phone:916-620-9495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-26
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician