MEDICARE: LYDIA ANNE MILLER

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	225800000X	Recreation Therapist		IN

General Provider Information

NPI Number	:	1790649572
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYDIA ANNE MILLER

Provider Business Mailing Address
First Line	:	4415 PIMLICO DR UNIT 204
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46845-2097
Country	:	US
Telephone Number	:	567-303-2232
Fax Number	:

Provider Business Practice Location Address
First Line	:	1400 D AIRPORT OFFICE PARK
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825
Country	:	US
Telephone Number	:	260-702-9141
Fax Number	:

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

Provider Enumeration Date	:	12/15/2025
Last Update Date	:	12/15/2025

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