Basic Information
| Provider Information | |||||||||
| NPI: | 1083113369 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LYSAK | ||||||||
| FirstName: | LAURIE | ||||||||
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| Credential: | OTRL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 132 CURRY AVE | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480671904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2487334325 | ||||||||
| FaxNumber: | 2482687979 | ||||||||
| Practice Location | |||||||||
| Address1: | 2512 ROCHESTER RD | ||||||||
| Address2: | |||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2487334325 | ||||||||
| FaxNumber: | 2482687979 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2018 | ||||||||
| LastUpdateDate: | 01/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 5201009827 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.