Provider Demographics
NPI:1902386915
Name:PROTHRO, LYDIA (PTA)
Entity Type:Individual
Prefix:MRS
First Name:LYDIA
Middle Name:
Last Name:PROTHRO
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 CAMDEN HL
Mailing Address - Street 2:
Mailing Address - City:HAUGHTON
Mailing Address - State:LA
Mailing Address - Zip Code:71037-8779
Mailing Address - Country:US
Mailing Address - Phone:318-347-0797
Mailing Address - Fax:
Practice Address - Street 1:6969 FERN AVE LOOP
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-4159
Practice Address - Country:US
Practice Address - Phone:318-383-0022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-19
Last Update Date:2018-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA10065R225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant