Provider Demographics
NPI:1366640625
Name:GRYSKEVICZ, LISA ANN (OTRL)
Entity type:Individual
Prefix:MISS
First Name:LISA
Middle Name:ANN
Last Name:GRYSKEVICZ
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 PRIESTLY ST
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-2515
Mailing Address - Country:US
Mailing Address - Phone:570-821-1180
Mailing Address - Fax:
Practice Address - Street 1:1000 W 27TH ST
Practice Address - Street 2:
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18202-9604
Practice Address - Country:US
Practice Address - Phone:570-454-8888
Practice Address - Fax:570-459-9252
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOC003420L225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist