Provider Demographics
NPI:1629484449
Name:LYSCIO, THOMAS (DPT)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:LYSCIO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8317 BASS LAKE RD
Mailing Address - Street 2:APARTMENT 204
Mailing Address - City:NEW HOPE
Mailing Address - State:MN
Mailing Address - Zip Code:55428-5336
Mailing Address - Country:US
Mailing Address - Phone:218-330-2816
Mailing Address - Fax:
Practice Address - Street 1:1107 HART BLVD
Practice Address - Street 2:SUITE 10
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-8538
Practice Address - Country:US
Practice Address - Phone:763-295-6878
Practice Address - Fax:763-271-6860
Is Sole Proprietor?:No
Enumeration Date:2014-07-02
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3167225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3167OtherTEMPORARY PERMIT - PHYSICAL THERAPIST