Provider Demographics
NPI:1881188597
Name:ALLISON, LYDIA JOY (LCMT)
Entity Type:Individual
Prefix:MRS
First Name:LYDIA
Middle Name:JOY
Last Name:ALLISON
Suffix:
Gender:F
Credentials:LCMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2145 FORD PKWY
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-1900
Mailing Address - Country:US
Mailing Address - Phone:651-757-6071
Mailing Address - Fax:
Practice Address - Street 1:2933 29TH AVE. S.
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406
Practice Address - Country:US
Practice Address - Phone:651-757-6071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20140002939225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN20140002939Medicaid
20140002939OtherMASSAGE THERAPY
MN$$$$$$$$$Medicaid