Lyddia Revell, DSC

Primary specialty

Occupational TherapistTaxonomy code 225X00000X

License

5857-26 Issued in WI

Practice address

3551 Roger Brooke Dr
Jbsa Ft Sam Houston, TX 78234

Phone

(262) 501-9788

NPI assigned

Jun 13, 2016

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other names 1

• Lyddia Petrofsky Former name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1465776000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1682899200000",
    "number": "1275982092",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "419 BELMONT UNIT 1",
            "city": "SAN ANTONIO",
            "state": "TX",
            "postal_code": "782023135",
            "telephone_number": "262-501-9788"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3551 ROGER BROOKE DR",
            "city": "JBSA FT SAM HOUSTON",
            "state": "TX",
            "postal_code": "78234",
            "telephone_number": "262-501-9788"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1407 Saint Andrew St",
            "address_2": "Ste 100",
            "address_purpose": "LOCATION",
            "city": "LA Crosse",
            "state": "WI",
            "postal_code": "546033301",
            "country_code": "US",
            "telephone_number": "715-743-5410",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "REVELL",
        "first_name": "LYDDIA",
        "name_prefix": "Dr.",
        "credential": "DSC",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2016-06-13",
        "last_updated": "2023-05-01",
        "certification_date": "2023-05-01",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225X00000X",
            "taxonomy_group": "",
            "desc": "Occupational Therapist",
            "state": "WI",
            "license": "5857-26",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "LYDDIA",
            "last_name": "PETROFSKY",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Swetha Ram, DO
• Amanda Vaquera Ramirez, APRN, FNP-C
• Dominic Samuel Ratto, M.D.
• Edward Andrew Rauch Jr., DNP, APRN
• Tyra Reed, MD
• Geovanny F Reyes-Matute, MD
• Laura Nicole Reyna, FNP
• Sean Christopher Reynolds, DMD
• Erica Rich, MD
• Michael F Richards, M.D.

• Occupational Therapist in Jbsa Ft Sam Houston, TX
• Providers in Jbsa Ft Sam Houston, TX by specialty
• Occupational Therapist in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 1, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.