Provider Demographics
NPI:1982191680
Name:WEDDERBURN, LYDIA SHANTERA
Entity Type:Individual
Prefix:MS
First Name:LYDIA
Middle Name:SHANTERA
Last Name:WEDDERBURN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 S HIGHWAY 29
Mailing Address - Street 2:
Mailing Address - City:CANTONMENT
Mailing Address - State:FL
Mailing Address - Zip Code:32533-5808
Mailing Address - Country:US
Mailing Address - Phone:850-968-3565
Mailing Address - Fax:
Practice Address - Street 1:2420 S HIGHWAY 29
Practice Address - Street 2:
Practice Address - City:CANTONMENT
Practice Address - State:FL
Practice Address - Zip Code:32533-5808
Practice Address - Country:US
Practice Address - Phone:850-968-3565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-18
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)