Provider Demographics
NPI:1497410450
Name:LYSIAK, LAUREN BETH
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:BETH
Last Name:LYSIAK
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 1:109 WARRINGTON DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-1122
Mailing Address - Country:US
Mailing Address - Phone:585-259-9909
Mailing Address - Fax:
Practice Address - Street 1:109 WARRINGTON DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-1122
Practice Address - Country:US
Practice Address - Phone:585-259-9909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-04
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017272225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist