Provider Demographics
NPI:1285952382
Name:LYSIUK, ALICIA (LAT, ATC, MS)
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:
Last Name:LYSIUK
Suffix:
Gender:F
Credentials:LAT, ATC, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10752 CHESTNUT HEATH CT
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-6117
Mailing Address - Country:US
Mailing Address - Phone:317-417-6217
Mailing Address - Fax:
Practice Address - Street 1:3125 S SCATTERFIELD RD STE 210
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46013-1804
Practice Address - Country:US
Practice Address - Phone:765-298-4311
Practice Address - Fax:765-298-4312
Is Sole Proprietor?:No
Enumeration Date:2010-05-13
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36001004A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer