MEDICARE: DONNA REBECCA LYDY BCBA, COBA, LBA

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	103K00000X	Behavior Analyst	1-14-9541	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7401001073	OTHER	MI	DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS
2	1-14-9541	OTHER		BCBA CERTIFICATE
3	COBA.116	OTHER	OH	OHIO BOARD OF PSYCHOLOGY

General Provider Information

NPI Number	:	1720484355
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONNA REBECCA LYDY BCBA, COBA, LBA

Provider Business Mailing Address
First Line	:	DEPT LA 22763
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91185-2763
Country	:	US
Telephone Number	:	866-523-4268
Fax Number	:

Provider Business Practice Location Address
First Line	:	3070 RIVERSIDE DR STE 200
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43221-2547
Country	:	US
Telephone Number	:	866-523-4268
Fax Number	:

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

Provider Enumeration Date	:	11/10/2014
Last Update Date	:	10/31/2023

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