Provider Demographics
NPI:1568772143
Name:PROVOST, LYDIA M (CMT)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:M
Last Name:PROVOST
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1848 S. GENOA STREET
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80017
Mailing Address - Country:US
Mailing Address - Phone:303-564-7032
Mailing Address - Fax:
Practice Address - Street 1:2226 SOUTH FRASER STREET,
Practice Address - Street 2:UNIT 5
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80014-4534
Practice Address - Country:US
Practice Address - Phone:303-695-1609
Practice Address - Fax:303-695-0382
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-15
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9091, MT225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist