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General NPI Number Information
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NPI Number | 1801190749
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Entity Type | Individual
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Provider Name | KIMBERLY ANN LYDTIN M.A., CCC-SLP, TSHH
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Gender | Female
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Dates
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Enumeration Date | 01/07/2011
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Last Update Date | 01/07/2011
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Provider Practice Location Address
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Address Line | 14408 GRAVETT RD
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City | FLUSHING
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State | NY
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Zip | 11367-1339
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Country | US
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Telephone | 347-307-4932
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Fax |
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Provider Business Mailing Address
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Address Line | 14408 GRAVETT RD
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City | FLUSHING
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State | NY
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Zip | 11367-1339
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Country | US
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Telephone | 347-307-4932
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 016434-1
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License Number State | NY
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