Provider Demographics
NPI:1982486015
Name:COALBURN, LYDIA SUSAN
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:SUSAN
Last Name:COALBURN
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 1:1820 S 750 W
Mailing Address - Street 2:
Mailing Address - City:RUSSIAVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46979-9736
Mailing Address - Country:US
Mailing Address - Phone:765-461-3760
Mailing Address - Fax:
Practice Address - Street 1:1111 N COURTLAND AVE
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-2755
Practice Address - Country:US
Practice Address - Phone:765-461-3760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-13
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN29001974A2355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant