Provider Demographics
NPI:1740538503
Name:MICHNO, LISA H (MA, SACT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:H
Last Name:MICHNO
Suffix:
Gender:F
Credentials:MA, SACT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:HACKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:122 E COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-5794
Mailing Address - Country:US
Mailing Address - Phone:920-996-3264
Mailing Address - Fax:920-830-5970
Practice Address - Street 1:1095 MIDWAY RD
Practice Address - Street 2:
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-1115
Practice Address - Country:US
Practice Address - Phone:920-720-2300
Practice Address - Fax:920-720-3719
Is Sole Proprietor?:No
Enumeration Date:2012-08-27
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16101101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)