Healthcare Provider Details

I. General information

NPI: 1114315595
Provider Name (Legal Business Name): CYNTHIA JEAN DISHMAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2015
Last Update Date: 10/22/2020
Certification Date: 10/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

341 BOGLE ST STE A
SOMERSET KY
42503-2815
US

IV. Provider business mailing address

PO BOX 1080
BURKESVILLE KY
42717-1080
US

V. Phone/Fax

Practice location:
  • Phone: 606-677-0201
  • Fax: 606-677-0208
Mailing address:
  • Phone: 270-858-6655
  • Fax: 270-858-4607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number252371
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: