Provider Demographics
NPI:1366530008
Name:LYSNE, MARK CARL (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:CARL
Last Name:LYSNE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 W CAVOUR AVE
Mailing Address - Street 2:P.O. BOX 713
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-2103
Mailing Address - Country:US
Mailing Address - Phone:218-998-3123
Mailing Address - Fax:218-998-3126
Practice Address - Street 1:225 W CAVOUR AVE
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-2103
Practice Address - Country:US
Practice Address - Phone:218-998-3123
Practice Address - Fax:218-998-3126
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4575103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical