Provider Demographics
NPI:1871831313
Name:LYDING, KACIE CHRISTINE (PT)
Entity Type:Individual
Prefix:
First Name:KACIE
Middle Name:CHRISTINE
Last Name:LYDING
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15410 S MOUNTAIN PKWY
Mailing Address - Street 2:112
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-6691
Mailing Address - Country:US
Mailing Address - Phone:480-689-5520
Mailing Address - Fax:
Practice Address - Street 1:8725 S KYRENE RD
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85284-2116
Practice Address - Country:US
Practice Address - Phone:480-756-8617
Practice Address - Fax:480-820-9909
Is Sole Proprietor?:No
Enumeration Date:2013-01-17
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9860225100000X
2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic