Provider Demographics
NPI:1992006258
Name:COOLIDGE, LYDIA MARIA (MS)
Entity Type:Individual
Prefix:MRS
First Name:LYDIA
Middle Name:MARIA
Last Name:COOLIDGE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MISS
Other - First Name:LYDIA
Other - Middle Name:MARIA
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:866 W IOWA AVE
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94086-7568
Mailing Address - Country:US
Mailing Address - Phone:925-787-2316
Mailing Address - Fax:
Practice Address - Street 1:4155 MOORPARK AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95117-1714
Practice Address - Country:US
Practice Address - Phone:888-996-9886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-03
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6664235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist