Provider Demographics
NPI:1467182014
Name:ROOT, LYDIA MARIE
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:MARIE
Last Name:ROOT
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 1:289 HOYAL LN
Mailing Address - Street 2:
Mailing Address - City:SPRING CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37381-4124
Mailing Address - Country:US
Mailing Address - Phone:612-816-6780
Mailing Address - Fax:
Practice Address - Street 1:2090 W MADISON AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TN
Practice Address - Zip Code:37303-3950
Practice Address - Country:US
Practice Address - Phone:423-405-3075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-15
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225X00000X
TN7356225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist