Provider Demographics
NPI:1720017106
Name:LISKA, MICHELLE L (LMSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:LISKA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 N OSSEO RD
Mailing Address - Street 2:PO BOX 187
Mailing Address - City:HILLSDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49242-9714
Mailing Address - Country:US
Mailing Address - Phone:517-414-7749
Mailing Address - Fax:
Practice Address - Street 1:101 E BACON ST SUITE 201
Practice Address - Street 2:
Practice Address - City:HILLSDALE
Practice Address - State:MI
Practice Address - Zip Code:49242-1666
Practice Address - Country:US
Practice Address - Phone:517-414-7749
Practice Address - Fax:888-414-2153
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010825681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP34770001Medicare PIN
MI0P34770Medicare PIN