1336417963 NPI number — MS. LYDIA LAWRENCE HYDE MS, CCC-SLP

Table of content: MS. LYDIA LAWRENCE HYDE MS, CCC-SLP (NPI 1336417963)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336417963 NPI number — MS. LYDIA LAWRENCE HYDE MS, CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HYDE
Provider First Name:
LYDIA
Provider Middle Name:
LAWRENCE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MS, CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336417963
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1717 IGNACIO BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NOVATO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94949-4961
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
510-472-5352
Provider Business Mailing Address Fax Number:
707-762-1254

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1717 IGNACIO BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NOVATO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94949-4961
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-472-5352
Provider Business Practice Location Address Fax Number:
707-762-1254
Provider Enumeration Date:
12/10/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  14058 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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