MEDICARE: DR. LYDIA A WARDIN PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103G00000X	Clinical Neuropsychologist	071009599	IL

General Provider Information

NPI Number	:	1255853073
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LYDIA A WARDIN PSYD

Provider Business Mailing Address
First Line	:	6033 N SHERIDAN RD STE S7
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-3013
Country	:	US
Telephone Number	:	855-264-9355
Fax Number	:	877-259-2359

Provider Business Practice Location Address
First Line	:	6033 N SHERIDAN RD STE S7
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-3013
Country	:	US
Telephone Number	:	855-264-9355
Fax Number	:	877-259-2359

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2017
Last Update Date	:	04/04/2018

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