Healthcare Provider Details

I. General information

NPI: 1790649572
Provider Name (Legal Business Name): LYDIA ANNE MILLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 D AIRPORT OFFICE PARK
FORT WAYNE IN
46825
US

IV. Provider business mailing address

4415 PIMLICO DR UNIT 204
FORT WAYNE IN
46845-2097
US

V. Phone/Fax

Practice location:
  • Phone: 260-702-9141
  • Fax:
Mailing address:
  • Phone: 567-303-2232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: