Basic Information
| Provider Information | |||||||||
| NPI: | 1639249311 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CISSNA | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | WILLIAM | ||||||||
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| Credential: | LPCA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 207 COLLEGE ST | ||||||||
| Address2: | |||||||||
| City: | HORSE CAVE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427491210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2709015000 | ||||||||
| FaxNumber: | 2708425268 | ||||||||
| Practice Location | |||||||||
| Address1: | 822 WOODWAY ST | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421012771 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2709015000 | ||||||||
| FaxNumber: | 2708425268 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 0197 | KY | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 60604011 | 05 | KY | MEDICAID |