Provider Demographics
NPI:1720698509
Name:GETAWERU, LYDDIA (MBA, LNHA, ALM)
Entity Type:Individual
Prefix:
First Name:LYDDIA
Middle Name:
Last Name:GETAWERU
Suffix:
Gender:F
Credentials:MBA, LNHA, ALM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2767 W PEGGY DR
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-6686
Mailing Address - Country:US
Mailing Address - Phone:480-656-5357
Mailing Address - Fax:
Practice Address - Street 1:2767 W PEGGY DR
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-6686
Practice Address - Country:US
Practice Address - Phone:480-656-5357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-05
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH6339323P00000X, 320800000X
AZ347E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
No347E00000XTransportation ServicesTransportation Broker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH6339Medicaid