Provider Demographics
NPI:1891570412
Name:TART, LYDIA GRACE (DPT)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:GRACE
Last Name:TART
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:DR
Other - First Name:LYDIA
Other - Middle Name:
Other - Last Name:TART
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPT
Mailing Address - Street 1:1601 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27608-2529
Mailing Address - Country:US
Mailing Address - Phone:919-820-3305
Mailing Address - Fax:
Practice Address - Street 1:7900 CREEDMOOR RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27613-4382
Practice Address - Country:US
Practice Address - Phone:919-364-8427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP22569225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist