Healthcare Provider Details

I. General information

NPI: 1780355867
Provider Name (Legal Business Name): LYDIA J MATHIS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2021
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 30TH ST OFC 100A
BOULDER CO
80301-1088
US

IV. Provider business mailing address

3800 COLORADO AVE UNIT B
BOULDER CO
80303-2102
US

V. Phone/Fax

Practice location:
  • Phone: 720-310-5512
  • Fax:
Mailing address:
  • Phone: 937-999-8374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC.0022484
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC.0022484
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: