MEDICARE: MR. ALEC KISSACK LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	18915	TX
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	10861	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1639241813	OTHER	TX	MILITARY
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639241813
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ALEC KISSACK LPC

Provider Business Mailing Address
First Line	:	20415 GULF VICTORY WAY
Second Line	:
City	:	FORT BLISS
State	:	TX
Zip	:	79918-8066
Country	:	US
Telephone Number	:	915-217-3314
Fax Number	:

Provider Business Practice Location Address
First Line	:	20415 GULF VICTORY WAY
Second Line	:
City	:	FORT BLISS
State	:	TX
Zip	:	79918-8066
Country	:	US
Telephone Number	:	915-351-2555
Fax Number	:	915-744-4833

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/14/2006
Last Update Date	:	11/02/2023

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