MEDICARE: MR. BRIAN S HISSOM MA, LPC, NCC

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	2376	NC

General Provider Information

NPI Number	:	1770683385
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRIAN S HISSOM MA, LPC, NCC

Provider Business Mailing Address
First Line	:	321 7TH ST NE
Second Line	:	SUITE B
City	:	HICKORY
State	:	NC
Zip	:	28601-5113
Country	:	US
Telephone Number	:	828-485-2195
Fax Number	:	828-485-2197

Provider Business Practice Location Address
First Line	:	321 7TH ST NE
Second Line	:	SUITE B
City	:	HICKORY
State	:	NC
Zip	:	28601-5113
Country	:	US
Telephone Number	:	828-485-2195
Fax Number	:	828-485-2197

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

Provider Enumeration Date	:	09/24/2006
Last Update Date	:	07/08/2007

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