Provider Demographics
NPI:1992894224
Name:LISKA, JOANN W (MSW LCSW SAC CCS)
Entity type:Individual
Prefix:
First Name:JOANN
Middle Name:W
Last Name:LISKA
Suffix:
Gender:F
Credentials:MSW LCSW SAC CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 LAKELAND RD
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-3836
Mailing Address - Country:US
Mailing Address - Phone:715-526-5547
Mailing Address - Fax:715-526-5542
Practice Address - Street 1:504 LAKELAND RD
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-3836
Practice Address - Country:US
Practice Address - Phone:715-526-5547
Practice Address - Fax:715-526-5542
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI39123101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39123OtherLICENSE #
WI39625700Medicaid