Provider Demographics
NPI:1629553235
Name:LYSKO, ALYSSA (MA)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:LYSKO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:464 S MARIE ST
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48186-3816
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 CORPORATE OFFICE DR STE 300
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MI
Practice Address - Zip Code:48381-5002
Practice Address - Country:US
Practice Address - Phone:734-787-6704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-28
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301017645103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist