Healthcare Provider Details

I. General information

NPI: 1275354185
Provider Name (Legal Business Name): LEAH M LYSAGHT OT/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2024
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 BRIM ST
DESLOGE MO
63601-3441
US

IV. Provider business mailing address

120 LOUISE ST
BONNE TERRE MO
63628-1251
US

V. Phone/Fax

Practice location:
  • Phone: 573-431-0223
  • Fax:
Mailing address:
  • Phone: 573-952-6225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2023010869
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: