Provider Demographics
NPI:1083423909
Name:MEACHAM, LYDIA
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:MEACHAM
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 BOULEVARD OF AMERICAS STE 304
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-4960
Mailing Address - Country:US
Mailing Address - Phone:402-252-1363
Mailing Address - Fax:
Practice Address - Street 1:27777 INKSTER RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-5310
Practice Address - Country:US
Practice Address - Phone:855-772-8847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-06
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
INRBT-23-292929106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician