| Doctor Name: | LISA C MYCANKA |
| NPI Number: | 1194888222 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | 3586 |
| Business Practice Address: | 325 Butts Ave Tomah, WI - 546601412 |
| Business Phone Number: | 6083725951 |
| Business Fax Number: | 6083723436 |
| Mailing Address: | 325 Butts Ave, TOMAH |
| State: | WI |
| Postal Code: | 546601412 |
| Phone Number: | 6083725951 |
| Fax Number: | 6083723436 |
| NPI Enumeration Date: | 12/19/2006 |
| NPI Last Update Date: | 07/28/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 1041C0700X |
| License Number: | 3586 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | KY |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Social Worker |
| Taxonomy Specialization: | Clinical |
| Taxonomy Definition: | A social worker who holds a master |