Provider Demographics
NPI:1184014292
Name:LASZCZAK, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:LASZCZAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9023 LUNAR AVE
Mailing Address - Street 2:APT 204
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-3329
Mailing Address - Country:US
Mailing Address - Phone:815-277-7547
Mailing Address - Fax:
Practice Address - Street 1:605 EDWARD DR
Practice Address - Street 2:
Practice Address - City:ROMEOVILLE
Practice Address - State:IL
Practice Address - Zip Code:60446-6507
Practice Address - Country:US
Practice Address - Phone:815-556-2487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-27
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160006380225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant