Healthcare Provider Details

I. General information

NPI: 1023139219
Provider Name (Legal Business Name): MISS LISA MARIE WYSOCKI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8930 EMPERORS CT
INDIANAPOLIS IN
46234-9599
US

IV. Provider business mailing address

8930 EMPERORS CT
INDIANAPOLIS IN
46234-9599
US

V. Phone/Fax

Practice location:
  • Phone: 316-271-9356
  • Fax: 317-271-7347
Mailing address:
  • Phone: 316-271-9356
  • Fax: 317-271-7347

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number533007
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: