Provider Demographics
NPI:1457835035
Name:GUDYASOVA, LIDIA
Entity Type:Individual
Prefix:
First Name:LIDIA
Middle Name:
Last Name:GUDYASOVA
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 1:1222 SUZANN DR
Mailing Address - Street 2:
Mailing Address - City:WARRINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:18976-1837
Mailing Address - Country:US
Mailing Address - Phone:267-290-0261
Mailing Address - Fax:215-798-8062
Practice Address - Street 1:1222 SUZANN DR
Practice Address - Street 2:
Practice Address - City:WARRINGTON
Practice Address - State:PA
Practice Address - Zip Code:18976-1837
Practice Address - Country:US
Practice Address - Phone:267-290-0261
Practice Address - Fax:215-798-1460
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator