Healthcare Provider Details

I. General information

NPI: 1972412708
Provider Name (Legal Business Name): SUZANNE M LYONS PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUE LYONS PTA

II. Dates (important events)

Enumeration Date: 09/07/2026
Last Update Date: 09/07/2026
Certification Date: 09/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 FAIRWAY DR
FREEPORT IL
61032-6600
US

IV. Provider business mailing address

5234 S WILLOW RD
STOCKTON IL
61085-9405
US

V. Phone/Fax

Practice location:
  • Phone: 815-599-6340
  • Fax:
Mailing address:
  • Phone: 815-762-9785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160.020741
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: