Provider Demographics
NPI:1982187118
Name:THREATT, LYDIA (APC)
Entity Type:Individual
Prefix:MS
First Name:LYDIA
Middle Name:
Last Name:THREATT
Suffix:
Gender:F
Credentials:APC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 HIGHWAY 16 W
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30223-7107
Mailing Address - Country:US
Mailing Address - Phone:770-229-3407
Mailing Address - Fax:770-229-3465
Practice Address - Street 1:1710 HIGHWAY 16 W
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30223-7107
Practice Address - Country:US
Practice Address - Phone:770-229-3407
Practice Address - Fax:770-229-3465
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC006571101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor