Healthcare Provider Details

I. General information

NPI: 1871831313
Provider Name (Legal Business Name): KACIE CHRISTINE LYDING PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2013
Last Update Date: 01/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8725 S KYRENE RD
TEMPE AZ
85284-2116
US

IV. Provider business mailing address

15410 S MOUNTAIN PKWY 112
PHOENIX AZ
85044-6691
US

V. Phone/Fax

Practice location:
  • Phone: 480-756-8617
  • Fax: 480-820-9909
Mailing address:
  • Phone: 480-689-5520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number9860
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: