Provider Demographics
NPI:1316389091
Name:RODRIGUEZ, LYDIA M
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:M
Last Name:RODRIGUEZ
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 1:91 CALLE WILLIE ROSARIO
Mailing Address - Street 2:
Mailing Address - City:COAMO
Mailing Address - State:PR
Mailing Address - Zip Code:00769-3015
Mailing Address - Country:US
Mailing Address - Phone:787-934-9285
Mailing Address - Fax:
Practice Address - Street 1:91 CALLE WILLIE ROSARIO
Practice Address - Street 2:
Practice Address - City:COAMO
Practice Address - State:PR
Practice Address - Zip Code:00769-3015
Practice Address - Country:US
Practice Address - Phone:787-934-9285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR631225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR631OtherLICENCIA PROFESIONAL DEL ESTADO