Provider Demographics
NPI:1053637355
Name:GARRISON, LYDDIA K (DPT)
Entity Type:Individual
Prefix:
First Name:LYDDIA
Middle Name:K
Last Name:GARRISON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:LYDDIA
Other - Middle Name:K
Other - Last Name:GAMMAGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:3082 CATON FARM RD
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-1455
Practice Address - Country:US
Practice Address - Phone:815-577-9936
Practice Address - Fax:815-577-9938
Is Sole Proprietor?:No
Enumeration Date:2010-04-12
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-016409225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00865616OtherMEDICARE RR
ILP00865616OtherMEDICARE RR
IL216859040Medicare PIN