| Doctor Name: | LYDIA M. PROVOST |
| NPI Number: | 1568772143 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | C.M.T. |
| License Number: | 9091, MT |
| Business Practice Address: | 2226 South Fraser Street, Unit 5 Aurora, CO - 800144534 |
| Business Phone Number: | 3036951609 |
| Business Fax Number: | 3036950382 |
| Mailing Address: | 1848 S. Genoa Street, AURORA |
| State: | CO |
| Postal Code: | 80017 |
| Phone Number: | 3035647032 |
| Fax Number: | |
| NPI Enumeration Date: | 10/15/2010 |
| NPI Last Update Date: | 10/15/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 225700000X |
| License Number: | 9091, MT |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CO |
| Taxonomy Type: | Respiratory, Developmental, Rehabilitative and Restorative Service Providers |
| Taxonomy Classification: | Massage Therapist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual trained in the manipulation of tissues (as by rubbing, stroking, kneading, or tapping) with the hand or an instrument for remedial or hygienic purposes. |