MEDICARE: CHILD AND FAMILY PSYCHOLOGICAL SERVICES, LLC

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	101YM0800X	Mental Health Counselor	39002087A	IN
2	106H00000X	Marriage & Family Therapist
3	103TC0700X	Clinical Psychologist	20042096A	IN

General Provider Information

NPI Number	:	1679810444
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHILD AND FAMILY PSYCHOLOGICAL SERVICES, LLC

Provider Business Mailing Address
First Line	:	424 WASHINGTON ST STE 7
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47201-6790
Country	:	US
Telephone Number	:	812-374-2282
Fax Number	:

Provider Business Practice Location Address
First Line	:	424 WASHINGTON ST STE 7
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47201-6790
Country	:	US
Telephone Number	:	812-374-2282
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL PSYCHOLOGIST
Name	:	DR. JESSICA ALYCE BRYANT BISSEY
Credential	:	PSYD
Telephone Number	:	812-374-2282

Provider Enumeration Date	:	01/13/2013
Last Update Date	:	01/13/2013

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