Provider Demographics
NPI:1114161734
Name:MAXWELL, LYDIA L (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:L
Last Name:MAXWELL
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16809 MAPLE LANE DR
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-2843
Mailing Address - Country:US
Mailing Address - Phone:765-427-9394
Mailing Address - Fax:
Practice Address - Street 1:16809 MAPLE LANE DR
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-2843
Practice Address - Country:US
Practice Address - Phone:765-427-9394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-27
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.009375235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist