Healthcare Provider Details

I. General information

NPI: 1649804857
Provider Name (Legal Business Name): LYDIA KATHERINE HIGGS MS, LCGC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2020
Last Update Date: 02/26/2020
Certification Date: 02/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 S JEFFERSON ST
ROANOKE VA
24016-4705
US

IV. Provider business mailing address

1211 S JEFFERSON ST
ROANOKE VA
24016-4705
US

V. Phone/Fax

Practice location:
  • Phone: 540-985-9889
  • Fax: 540-857-9130
Mailing address:
  • Phone: 540-985-9889
  • Fax: 540-857-9130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number0139000003
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: