MEDICARE: K LIDZ NP IN PSYCHIATRY PLLC

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1427894310
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	K LIDZ NP IN PSYCHIATRY PLLC

Provider Business Mailing Address
First Line	:	1983 NEWBERRY LN
Second Line	:
City	:	TEGA CAY
State	:	SC
Zip	:	29708-8438
Country	:	US
Telephone Number	:	803-619-9846
Fax Number	:	803-913-5275

Provider Business Practice Location Address
First Line	:	6520 SW THISTLE TER
Second Line	:
City	:	PALM CITY
State	:	FL
Zip	:	34990-3857
Country	:	US
Telephone Number	:	803-619-9846
Fax Number	:	803-913-5275

Authorized Official
Title or Position	:	OWNER
Name	:	KATHERINE LIDZ
Credential	:
Telephone Number	:	803-619-9846

Provider Enumeration Date	:	07/01/2024
Last Update Date	:	12/18/2024

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