Provider Demographics
NPI:1225554959
Name:LIDY, ANITA SUE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:ANITA
Middle Name:SUE
Last Name:LIDY
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 E 1125 AVE
Mailing Address - Street 2:
Mailing Address - City:MULBERRY GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:62262-3509
Mailing Address - Country:US
Mailing Address - Phone:618-292-9613
Mailing Address - Fax:
Practice Address - Street 1:1017 W FLETCHER ST
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:IL
Practice Address - Zip Code:62471-1007
Practice Address - Country:US
Practice Address - Phone:618-283-5166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-15
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.005588235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist