Healthcare Provider Details

I. General information

NPI: 1134895923
Provider Name (Legal Business Name): MICHAEL LYSAUGHT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2021
Last Update Date: 08/20/2021
Certification Date: 08/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 WILLOW ST
FRANKFORT IL
60423-1140
US

IV. Provider business mailing address

2628 W 107TH ST
CHICAGO IL
60655-1707
US

V. Phone/Fax

Practice location:
  • Phone: 815-806-4685
  • Fax:
Mailing address:
  • Phone: 708-941-7336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number242.006.490
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: