Healthcare Provider Details

I. General information

NPI: 1215545264
Provider Name (Legal Business Name): LYDIA BLEVINS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2020
Last Update Date: 07/15/2020
Certification Date: 07/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 STANAFORD RD
BECKLEY WV
25801-3143
US

IV. Provider business mailing address

149 MAPLEWOOD RD
LESTER WV
25865-9580
US

V. Phone/Fax

Practice location:
  • Phone: 304-252-6317
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number001607
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: