Healthcare Provider Details

I. General information

NPI: 1861353161
Provider Name (Legal Business Name): GRACE MARIE LISCHKA MS, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GRACE MARIE MELSO MS, LAT, ATC

II. Dates (important events)

Enumeration Date: 11/18/2025
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4045 LANCER CIR
MANITOWOC WI
54220-2336
US

IV. Provider business mailing address

2473 PORTSIDE LN APT 19
MANITOWOC WI
54220-3421
US

V. Phone/Fax

Practice location:
  • Phone: 920-682-0215
  • Fax:
Mailing address:
  • Phone: 920-901-5586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number330839
License Number StateWI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: