Healthcare Provider Details

I. General information

NPI: 1952957565
Provider Name (Legal Business Name): LISA MICHELLE DYBALSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2019
Last Update Date: 07/11/2022
Certification Date: 07/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 W 80TH PL
MERRILLVILLE IN
46410-5432
US

IV. Provider business mailing address

2042 LAKEWOOD PL
CROWN POINT IN
46307-9330
US

V. Phone/Fax

Practice location:
  • Phone: 219-513-8311
  • Fax:
Mailing address:
  • Phone: 708-969-1138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160.008557
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06006122A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: