Provider Demographics
NPI:1609381979
Name:ANDERSON, LYDIA D (DPT)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:D
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1180 BEACON ST
Mailing Address - Street 2:STE 6C
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-3806
Mailing Address - Country:US
Mailing Address - Phone:719-244-8147
Mailing Address - Fax:
Practice Address - Street 1:3224 ORCHARD AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73012-9645
Practice Address - Country:US
Practice Address - Phone:719-244-8147
Practice Address - Fax:719-244-8147
Is Sole Proprietor?:No
Enumeration Date:2017-12-08
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA23611225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist