Provider Demographics
NPI:1518241355
Name:LISIK, KATRINA MARIE (LBSW)
Entity Type:Individual
Prefix:MS
First Name:KATRINA
Middle Name:MARIE
Last Name:LISIK
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:MS
Other - First Name:KATRINIA
Other - Middle Name:MARIE
Other - Last Name:TARALA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:70 LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48342-2033
Mailing Address - Country:US
Mailing Address - Phone:248-338-7458
Mailing Address - Fax:
Practice Address - Street 1:3353 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-9622
Practice Address - Country:US
Practice Address - Phone:989-746-9633
Practice Address - Fax:989-790-1488
Is Sole Proprietor?:No
Enumeration Date:2011-09-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802086512104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker