Provider Demographics
NPI:1700307360
Name:MORA, LYDIA
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:MORA
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 1:808 ELMWOOD ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-6266
Mailing Address - Country:US
Mailing Address - Phone:917-589-9733
Mailing Address - Fax:
Practice Address - Street 1:808 ELMWOOD ST
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-6266
Practice Address - Country:US
Practice Address - Phone:917-589-9733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-03
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No174400000XOther Service ProvidersSpecialist