Healthcare Provider Details

I. General information

NPI: 1457946832
Provider Name (Legal Business Name): LYDIA MCCORMICK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2021
Last Update Date: 04/11/2025
Certification Date: 04/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6800 PARAGON PL STE 237
RICHMOND VA
23230-1651
US

IV. Provider business mailing address

4213 OLDE LIBERTY RD
NORTH CHESTERFIELD VA
23236-4708
US

V. Phone/Fax

Practice location:
  • Phone: 804-562-9997
  • Fax:
Mailing address:
  • Phone: 804-475-3430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number0134000273
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: