Lydia Mikula Clackum, DPT

Primary specialty

Physical TherapistTaxonomy code 225100000X

License

PT013374 Issued in GA

Practice address

3455 Highway 81 South
Loganville, GA 30052-3918

Phone

(678) 635-8280

Fax

(678) 635-8285

NPI assigned

Jun 11, 2018

Last updated

Jun 11, 2018By the provider in NPPES

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

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Drayer Physical Therapy Georgia LLC

  • Physical Therapist
  • Monroe, GA
  • NPI 1568890382
  NPD (past)

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

{
    "created_epoch": "1528675200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1528675200000",
    "number": "1295228781",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3455 HIGHWAY 81 SOUTH",
            "city": "LOGANVILLE",
            "state": "GA",
            "postal_code": "300523918",
            "telephone_number": "770-554-0665",
            "fax_number": "770-554-0685"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3455 HIGHWAY 81 SOUTH",
            "city": "LOGANVILLE",
            "state": "GA",
            "postal_code": "300523918",
            "telephone_number": "678-635-8280",
            "fax_number": "678-635-8285"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CLACKUM",
        "first_name": "LYDIA",
        "middle_name": "MIKULA",
        "credential": "DPT",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2018-06-11",
        "last_updated": "2018-06-11",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "GA",
            "license": "PT013374",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Min Gi Cho
• Chosen Path Enterprises, LLC
• Lazina Choudhry, OD
• Christ the King Healthcare PC (Christ the King Medical Center)
• Circle of Care, Inc.
• Jordan T Cladd
• Carman Suzanne Clark, PSYCHOLOGIST, LPC
• Charli Hicks Clements
• Laura Coffee, MA SLP
• Lola Colbert, DDS

• Physical Therapist in Loganville, GA
• Providers in Loganville, GA by specialty
• Physical Therapist in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 11, 2018; 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.