Provider Demographics
NPI:1679996466
Name:KASZYNSKI, ILYSE LOGAN (MS, OTR/L)
Entity type:Individual
Prefix:MRS
First Name:ILYSE
Middle Name:LOGAN
Last Name:KASZYNSKI
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6565 CLOSE DRIVE
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430
Mailing Address - Country:US
Mailing Address - Phone:269-779-6111
Mailing Address - Fax:
Practice Address - Street 1:6565 HARTWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430
Practice Address - Country:US
Practice Address - Phone:269-779-6111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-29
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201008532225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist