Provider Demographics
NPI:1902196637
Name:LYKSTAD, LEEANN
Entity Type:Individual
Prefix:
First Name:LEEANN
Middle Name:
Last Name:LYKSTAD
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 1:323 N BRANCH ST
Mailing Address - Street 2:
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201-2030
Mailing Address - Country:US
Mailing Address - Phone:802-430-4432
Mailing Address - Fax:
Practice Address - Street 1:532 MAIN ST
Practice Address - Street 2:
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201-2875
Practice Address - Country:US
Practice Address - Phone:802-447-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-14
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist