Provider Demographics
NPI:1982780417
Name:FAZIO, LYDIA M (PT)
Entity Type:Individual
Prefix:MRS
First Name:LYDIA
Middle Name:M
Last Name:FAZIO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13121 MOUNT OLIVET RD
Mailing Address - Street 2:
Mailing Address - City:FELTON
Mailing Address - State:PA
Mailing Address - Zip Code:17322-8505
Mailing Address - Country:US
Mailing Address - Phone:410-583-1515
Mailing Address - Fax:419-583-2491
Practice Address - Street 1:15 N SYMINGTON AVE
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-2006
Practice Address - Country:US
Practice Address - Phone:410-456-2923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2014-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16450225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist