Healthcare Provider Details

I. General information

NPI: 1194947028
Provider Name (Legal Business Name): VIRGINIA LYDER PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 PLEASANT STREET
CONCORD NH
03301
US

IV. Provider business mailing address

4 AUTUMN RUN
HOOKSETT NH
03106
US

V. Phone/Fax

Practice location:
  • Phone: 603-224-6561
  • Fax:
Mailing address:
  • Phone: 603-494-3540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number0382
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: