Provider Demographics
NPI:1598809154
Name:LYDDY, MAURA C (DC)
Entity Type:Individual
Prefix:DR
First Name:MAURA
Middle Name:C
Last Name:LYDDY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1319 HUNTINGTON TPKE
Mailing Address - Street 2:
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-5316
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1077 BRIDGEPORT AVE
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-4622
Practice Address - Country:US
Practice Address - Phone:203-929-5700
Practice Address - Fax:203-929-5600
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000501111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1354489-000OtherSTATE ID
CT050000501CT05OtherANTHEM BCBS ID
CT720209OtherCONNECTICARE
CT0609776OtherSTATE LLC