Provider Demographics
NPI:1407268022
Name:KAUFMAN, LYDIA MITCHELLE
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:MITCHELLE
Last Name:KAUFMAN
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 1:5800 AMERICAN BLVD W APT 528
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55437-1489
Mailing Address - Country:US
Mailing Address - Phone:310-497-1035
Mailing Address - Fax:
Practice Address - Street 1:5800 AMERICAN BLVD W APT 528
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55437-1489
Practice Address - Country:US
Practice Address - Phone:310-497-1035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-02
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111624225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist