Provider Demographics
NPI:1447504915
Name:LYDIC, CORI ELIZABETH
Entity type:Individual
Prefix:
First Name:CORI
Middle Name:ELIZABETH
Last Name:LYDIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11719 NE 95TH ST STE D
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98682-2444
Mailing Address - Country:US
Mailing Address - Phone:360-397-8246
Mailing Address - Fax:
Practice Address - Street 1:11719 NE 95TH ST STE D
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98682-2444
Practice Address - Country:US
Practice Address - Phone:360-397-8246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-05
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health