Provider Demographics
NPI:1891966297
Name:MYHRE, LISSA R (MS)
Entity Type:Individual
Prefix:
First Name:LISSA
Middle Name:R
Last Name:MYHRE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 S MAIN ST
Mailing Address - Street 2:PO BOX 8010
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-3977
Mailing Address - Country:US
Mailing Address - Phone:608-757-0404
Mailing Address - Fax:608-757-2319
Practice Address - Street 1:1 S MAIN ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-3977
Practice Address - Country:US
Practice Address - Phone:608-757-0404
Practice Address - Fax:608-757-2319
Is Sole Proprietor?:No
Enumeration Date:2008-03-13
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4254-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39642700Medicaid