Provider Demographics
NPI:1083130728
Name:DOUBLESTEIN, LYDIA HEEEUN (CM, IBCLC)
Entity Type:Individual
Prefix:MS
First Name:LYDIA
Middle Name:HEEEUN
Last Name:DOUBLESTEIN
Suffix:
Gender:F
Credentials:CM, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1940 OAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80521-4344
Mailing Address - Country:US
Mailing Address - Phone:231-675-8561
Mailing Address - Fax:
Practice Address - Street 1:720 S 333RD ST STE 130
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-7357
Practice Address - Country:US
Practice Address - Phone:253-766-5156
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-15
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001802367A00000X
106S00000X
L-159665174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty
No174N00000XOther Service ProvidersLactation Consultant, Non-RN