Provider Demographics
NPI:1144236258
Name:RADOSEVICH, LYDIA C (PT)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:C
Last Name:RADOSEVICH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:439 MECHEM DR.
Mailing Address - Street 2:
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88345
Mailing Address - Country:US
Mailing Address - Phone:505-257-1800
Mailing Address - Fax:505-257-2319
Practice Address - Street 1:439 MECHEM DR
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-6813
Practice Address - Country:US
Practice Address - Phone:505-257-1800
Practice Address - Fax:505-257-2319
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1781225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist