Basic Information
| Provider Information | |||||||||
| NPI: | 1396263497 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LYDELL | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 541 WOODPOND RD | ||||||||
| Address2: | |||||||||
| City: | CHESHIRE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064104343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2034648586 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6701 BERGENLINE AVE | ||||||||
| Address2: | |||||||||
| City: | WEST NEW YORK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070931704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2017589100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2017 | ||||||||
| LastUpdateDate: | 09/05/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA01752500 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 40QA01752500 | 01 | NJ | PHYSICAL THERAPY LISCENSE | OTHER |