Healthcare Provider Details

I. General information

NPI: 1093645038
Provider Name (Legal Business Name): MISS LYDIA DOUGLASS MULDOON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 E HENNEPIN AVE STE LL20
MINNEAPOLIS MN
55413-2738
US

IV. Provider business mailing address

1801 W FARM RD
LONG LAKE MN
55356-9308
US

V. Phone/Fax

Practice location:
  • Phone: 612-489-7044
  • Fax: 213-426-8025
Mailing address:
  • Phone: 763-656-3166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: