Provider Demographics
NPI:1184749806
Name:LYSEN, AMY LLOYD (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:LLOYD
Last Name:LYSEN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 E HORNE ST
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27520-2444
Mailing Address - Country:US
Mailing Address - Phone:919-614-0628
Mailing Address - Fax:
Practice Address - Street 1:447 VENTURE DR STE D
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-4765
Practice Address - Country:US
Practice Address - Phone:910-298-2331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2023-02-20
Deactivation Date:2023-01-19
Deactivation Code:
Reactivation Date:2023-02-07
Provider Licenses
StateLicense IDTaxonomies
NC4619235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC135J7OtherBCBS