Healthcare Provider Details

I. General information

NPI: 1285952382
Provider Name (Legal Business Name): ALICIA LYSIUK LAT, ATC, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2010
Last Update Date: 09/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3125 S SCATTERFIELD RD STE 210
ANDERSON IN
46013-1804
US

IV. Provider business mailing address

10752 CHESTNUT HEATH CT
NOBLESVILLE IN
46060-6117
US

V. Phone/Fax

Practice location:
  • Phone: 765-298-4311
  • Fax: 765-298-4312
Mailing address:
  • Phone: 317-417-6217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36001004A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: