Healthcare Provider Details

I. General information

NPI: 1104616531
Provider Name (Legal Business Name): CISCO COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2025
Last Update Date: 05/08/2025
Certification Date: 05/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 S POPLAR ST
CENTRALIA IL
62801-5172
US

IV. Provider business mailing address

1504 S POPLAR ST
CENTRALIA IL
62801-5172
US

V. Phone/Fax

Practice location:
  • Phone: 618-267-0305
  • Fax:
Mailing address:
  • Phone: 618-267-0305
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. WASHINGTON DIXON CISCO
Title or Position: CEO
Credential: MR
Phone: 618-267-0305