Provider Demographics
NPI:1689107161
Name:IRVIN, LYDIA (BCBA)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:IRVIN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6611 RIVERPLACE BLVD
Mailing Address - Street 2:ST 305
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78730
Mailing Address - Country:US
Mailing Address - Phone:512-798-3703
Mailing Address - Fax:
Practice Address - Street 1:6611 RIVERPLACE BLVD
Practice Address - Street 2:ST 305
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78730
Practice Address - Country:US
Practice Address - Phone:512-798-3703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-11
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11725772103K00000X
TX2101103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst