Provider Demographics
NPI:1164026662
Name:LIDY, MORGAN RAE
Entity Type:Individual
Prefix:
First Name:MORGAN
Middle Name:RAE
Last Name:LIDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DIETERICH
Mailing Address - State:IL
Mailing Address - Zip Code:62424-1123
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:208 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DIETERICH
Practice Address - State:IL
Practice Address - Zip Code:62424-1123
Practice Address - Country:US
Practice Address - Phone:217-821-7694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty