Provider Demographics
NPI:1386052033
Name:LYSAK, REBECCA (OT)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:LYSAK
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11182 ROSARITA DR
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3208
Mailing Address - Country:US
Mailing Address - Phone:909-499-0432
Mailing Address - Fax:
Practice Address - Street 1:8265 WHITE OAK AVE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-7671
Practice Address - Country:US
Practice Address - Phone:909-373-1641
Practice Address - Fax:909-373-0444
Is Sole Proprietor?:No
Enumeration Date:2014-07-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT 14429225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist