Healthcare Provider Details

I. General information

NPI: 1578335618
Provider Name (Legal Business Name): LYDIAS SMALL UNIQUE MINDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2023
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 RENDER ST
LAGRANGE GA
30241-3418
US

IV. Provider business mailing address

509 GREENVILLE ST
LAGRANGE GA
30241-3326
US

V. Phone/Fax

Practice location:
  • Phone: 706-883-5801
  • Fax:
Mailing address:
  • Phone: 706-883-5801
  • Fax: 706-416-2490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: LYDIA TIGGS
Title or Position: OWNER
Credential:
Phone: 706-883-5801