Provider Demographics
NPI:1962161000
Name:TATE, LYDIA DIANE (LAC)
Entity type:Individual
Prefix:MS
First Name:LYDIA
Middle Name:DIANE
Last Name:TATE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4035 SE 52ND AVE STE B
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-3913
Mailing Address - Country:US
Mailing Address - Phone:971-229-2140
Mailing Address - Fax:
Practice Address - Street 1:4035 SE 52ND AVE STE B
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-3913
Practice Address - Country:US
Practice Address - Phone:971-229-2140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-16
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC208176171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist