Healthcare Provider Details

I. General information

NPI: 1255853073
Provider Name (Legal Business Name): LYDIA A WARDIN PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2017
Last Update Date: 04/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6033 N SHERIDAN RD STE S7
CHICAGO IL
60660-3013
US

IV. Provider business mailing address

6033 N SHERIDAN RD STE S7
CHICAGO IL
60660-3013
US

V. Phone/Fax

Practice location:
  • Phone: 855-264-9355
  • Fax: 877-259-2359
Mailing address:
  • Phone: 855-264-9355
  • Fax: 877-259-2359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number071009599
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: