Provider Demographics
NPI:1740200682
Name:HYSSOP MODIFICATION SERVICES,INC
Entity Type:Organization
Organization Name:HYSSOP MODIFICATION SERVICES,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MAIN DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LARYSA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:MYKYTIUK
Authorized Official - Suffix:
Authorized Official - Credentials:7736263613
Authorized Official - Phone:773-626-3613
Mailing Address - Street 1:5835 W DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60651-1008
Mailing Address - Country:US
Mailing Address - Phone:773-626-3613
Mailing Address - Fax:
Practice Address - Street 1:5835 W DIVISION ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60651-1008
Practice Address - Country:US
Practice Address - Phone:773-626-3613
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty