MEDICARE: MRS. LYDIA ANN IVORY LPCI

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	66486	TX

General Provider Information

NPI Number	:	1881914380
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LYDIA ANN IVORY LPCI

Provider Business Mailing Address
First Line	:	6612 N RIVERSIDE DR
Second Line	:	140
City	:	FORT WORTH
State	:	TX
Zip	:	76137-6663
Country	:	US
Telephone Number	:	817-306-9770
Fax Number	:

Provider Business Practice Location Address
First Line	:	6612 N RIVERSIDE DR
Second Line	:	140
City	:	FORT WORTH
State	:	TX
Zip	:	76137-6663
Country	:	US
Telephone Number	:	817-306-9770
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2010
Last Update Date	:	06/07/2010

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