Provider Demographics
NPI:1265603617
Name:PAVELKA, LYDIA ELIZABETH (DPT)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:ELIZABETH
Last Name:PAVELKA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23000 MOAKLEY ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LEONARDTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20650-2915
Mailing Address - Country:US
Mailing Address - Phone:301-475-5830
Mailing Address - Fax:301-475-6507
Practice Address - Street 1:23000 MOAKLEY ST
Practice Address - Street 2:SUITE 101
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650-2915
Practice Address - Country:US
Practice Address - Phone:301-475-5830
Practice Address - Fax:301-475-6507
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-13
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH5530225100000X
CA33845225100000X
MD23256225100000X
ALPTH7148225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist