Provider Demographics
NPI:1790968352
Name:BRODEGARD, LYDIA RACHELE
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:RACHELE
Last Name:BRODEGARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 FOUNDRY ST
Mailing Address - Street 2:
Mailing Address - City:NEW MARTINSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26155-1142
Mailing Address - Country:US
Mailing Address - Phone:304-455-2441
Mailing Address - Fax:304-455-3446
Practice Address - Street 1:333 FOUNDRY ST
Practice Address - Street 2:
Practice Address - City:NEW MARTINSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26155-1142
Practice Address - Country:US
Practice Address - Phone:304-455-2441
Practice Address - Fax:304-455-3446
Is Sole Proprietor?:No
Enumeration Date:2007-12-06
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1238225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810010519Medicaid