Healthcare Provider Details

I. General information

NPI: 1639249311
Provider Name (Legal Business Name): CHARLES WILLIAM CISSNA LPCA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 WOODWAY ST
BOWLING GREEN KY
42101-2771
US

IV. Provider business mailing address

207 COLLEGE ST
HORSE CAVE KY
42749-1210
US

V. Phone/Fax

Practice location:
  • Phone: 270-901-5000
  • Fax: 270-842-5268
Mailing address:
  • Phone: 270-901-5000
  • Fax: 270-842-5268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0197
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: