Provider Demographics
NPI:1922840925
Name:SAN MIGUEL, LYDIA (LCDC)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:SAN MIGUEL
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1747 CITADEL PLZ
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-1097
Mailing Address - Country:US
Mailing Address - Phone:210-467-5395
Mailing Address - Fax:210-817-1114
Practice Address - Street 1:1747 CITADEL PLZ
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-1097
Practice Address - Country:US
Practice Address - Phone:210-467-5395
Practice Address - Fax:210-817-1114
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15087101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)