Healthcare Provider Details

I. General information

NPI: 1073707014
Provider Name (Legal Business Name): GLORIA SMITH CISSE LPC, LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2007
Last Update Date: 09/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3835 VINEVILLE AVE
MACON GA
31204-1864
US

IV. Provider business mailing address

2093 E NAPIER AVE
MACON GA
31204-3617
US

V. Phone/Fax

Practice location:
  • Phone: 478-471-7785
  • Fax:
Mailing address:
  • Phone: 478-743-8288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number004607
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number003871
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: