Provider Demographics
NPI:1821206608
Name:BRADFORTD OTIATO, LYDIA (MOT)
Entity Type:Individual
Prefix:MRS
First Name:LYDIA
Middle Name:
Last Name:BRADFORTD OTIATO
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 GEORGIAN CT
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-1878
Mailing Address - Country:US
Mailing Address - Phone:574-514-8127
Mailing Address - Fax:574-231-9021
Practice Address - Street 1:1818 GEORGIAN CT
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-1878
Practice Address - Country:US
Practice Address - Phone:574-514-8127
Practice Address - Fax:574-231-9021
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31003922A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist