Healthcare Provider Details

I. General information

NPI: 1710816608
Provider Name (Legal Business Name): LYDIA WOMBACHER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 HARBOR BEND CT STE 102
LAKE ST LOUIS MO
63367-1480
US

IV. Provider business mailing address

1280 SLEEPY HOLLOW DR
TROY MO
63379-2339
US

V. Phone/Fax

Practice location:
  • Phone: 636-695-2075
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081N0008X
TaxonomyNeuromuscular Medicine (Physical Medicine & Rehabilitation) Physician
License Number2081N0008X
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: