Provider Demographics
NPI:1457946832
Name:MCCORMICK, LYDIA MICHELLE
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:MICHELLE
Last Name:MCCORMICK
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 1:4213 OLDE LIBERTY RD
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23236-4708
Mailing Address - Country:US
Mailing Address - Phone:804-475-3430
Mailing Address - Fax:
Practice Address - Street 1:1107 ALVERSER DR
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-2655
Practice Address - Country:US
Practice Address - Phone:804-897-1753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-07
Last Update Date:2021-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0134000273103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst