Provider Demographics
NPI:1386128957
Name:HAREN, LYDIA (MS, LAT, ATC)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:HAREN
Suffix:
Gender:F
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1198 JONES BUTLER RD APT 2805
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77840-6455
Mailing Address - Country:US
Mailing Address - Phone:804-386-4773
Mailing Address - Fax:
Practice Address - Street 1:1198 JONES BUTLER RD APT 2805
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77840-6455
Practice Address - Country:US
Practice Address - Phone:804-386-4773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-19
Last Update Date:2019-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer