Provider Demographics
NPI:1609459734
Name:LYDICK, ZACHARY (PTA)
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:LYDICK
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 THORNHILL DR STE B
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60188-2772
Mailing Address - Country:US
Mailing Address - Phone:630-933-1500
Mailing Address - Fax:
Practice Address - Street 1:515 THORNHILL DR STE B
Practice Address - Street 2:
Practice Address - City:CAROL STREAM
Practice Address - State:IL
Practice Address - Zip Code:60188-2772
Practice Address - Country:US
Practice Address - Phone:630-933-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-05
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160008916225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant