Provider Demographics
NPI:1386843902
Name:LYDEARD, PAUL MATTHEW (PT)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:MATTHEW
Last Name:LYDEARD
Suffix:
Gender:M
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:PO BOX 20372
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-0944
Mailing Address - Country:US
Mailing Address - Phone:401-785-1016
Mailing Address - Fax:401-785-1018
Practice Address - Street 1:1539 ATWOOD AVE
Practice Address - Street 2:
Practice Address - City:JOHNSTON
Practice Address - State:RI
Practice Address - Zip Code:02919-3262
Practice Address - Country:US
Practice Address - Phone:401-351-0515
Practice Address - Fax:401-351-0530
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT02022225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIPT02022OtherSTATE LICENSE NUMBER