Provider Demographics
NPI:1528285947
Name:LYSKOWSKI, TERESA (TERRY) ROSE (PT)
Entity type:Individual
Prefix:MS
First Name:TERESA (TERRY)
Middle Name:ROSE
Last Name:LYSKOWSKI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:TERESA (TERRY)
Other - Middle Name:ROSE
Other - Last Name:RIEKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1203 ELMERINE AVE
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-3719
Mailing Address - Country:US
Mailing Address - Phone:573-635-9671
Mailing Address - Fax:
Practice Address - Street 1:1115 FAIRGROUNDS RD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-5443
Practice Address - Country:US
Practice Address - Phone:573-634-3070
Practice Address - Fax:573-636-3247
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO00692225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist