Provider Demographics
NPI:1275982092
Name:REVELL, LYDDIA (DSC)
Entity Type:Individual
Prefix:DR
First Name:LYDDIA
Middle Name:
Last Name:REVELL
Suffix:
Gender:F
Credentials:DSC
Other - Prefix:
Other - First Name:LYDDIA
Other - Middle Name:
Other - Last Name:PETROFSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:419 BELMONT UNIT 1
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78202-3135
Mailing Address - Country:US
Mailing Address - Phone:262-501-9788
Mailing Address - Fax:
Practice Address - Street 1:3551 ROGER BROOKE DR
Practice Address - Street 2:
Practice Address - City:JBSA FT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234
Practice Address - Country:US
Practice Address - Phone:262-501-9788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-13
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5857-26225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist