Healthcare Provider Details

I. General information

NPI: 1245816826
Provider Name (Legal Business Name): DAVID REED LYSAKOWSKI LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 BOND AVE
CENTREVILLE IL
62207-2326
US

IV. Provider business mailing address

5900 BOND AVE
CENTREVILLE IL
62207-2326
US

V. Phone/Fax

Practice location:
  • Phone: 619-332-5302
  • Fax: 618-332-5285
Mailing address:
  • Phone: 619-332-5302
  • Fax: 618-332-5285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149009090
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: