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General NPI Number Information
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NPI Number | 1821206608
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Entity Type | Individual
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Provider Name | LYDIA BRADFORTD OTIATO MOT
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Gender | Female
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Dates
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Enumeration Date | 05/18/2007
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Last Update Date | 12/12/2016
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Provider Practice Location Address
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Address Line | 1818 GEORGIAN CT
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City | SOUTH BEND
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State | IN
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Zip | 46614-1878
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Country | US
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Telephone | 574-514-8127
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Fax | 574-231-9021
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Provider Business Mailing Address
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Address Line | 1818 GEORGIAN CT
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City | SOUTH BEND
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State | IN
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Zip | 46614-1878
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Country | US
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Telephone | 574-514-8127
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Fax | 574-231-9021
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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 | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number | 31003922A
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License Number State | IN
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