Provider Demographics
NPI:1740655919
Name:LI, LYDIA GRACE
Entity type:Individual
Prefix:MRS
First Name:LYDIA
Middle Name:GRACE
Last Name:LI
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:LYDIA
Other - Middle Name:GRACE
Other - Last Name:NITCHMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13006 FREELAND RD
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20853-3031
Mailing Address - Country:US
Mailing Address - Phone:347-622-1451
Mailing Address - Fax:
Practice Address - Street 1:7811 MONTROSE RD STE 350
Practice Address - Street 2:
Practice Address - City:POTOMAC
Practice Address - State:MD
Practice Address - Zip Code:20854-3359
Practice Address - Country:US
Practice Address - Phone:301-417-8283
Practice Address - Fax:301-417-8306
Is Sole Proprietor?:No
Enumeration Date:2015-12-14
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039664225100000X
MD28386225100000X, 2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ4WFH1Medicare PIN
NY03248Medicare PIN