Provider Demographics
NPI:1821254764
Name:DAVIS, LYDIA ROSE
Entity Type:Individual
Prefix:MRS
First Name:LYDIA
Middle Name:ROSE
Last Name:DAVIS
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 1:1021 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-1405
Mailing Address - Country:US
Mailing Address - Phone:425-493-5800
Mailing Address - Fax:425-493-5801
Practice Address - Street 1:1021 N BROADWAY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-1405
Practice Address - Country:US
Practice Address - Phone:425-493-5800
Practice Address - Fax:425-493-5801
Is Sole Proprietor?:No
Enumeration Date:2008-07-30
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60144539101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health