Healthcare Provider Details

I. General information

NPI: 1508039140
Provider Name (Legal Business Name): CISSELSALTERNATIVE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2008
Last Update Date: 04/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 DAVENPORT DR
RAEFORD NC
28376-5425
US

IV. Provider business mailing address

126 DAVENPORT DR
RAEFORD NC
28376-5425
US

V. Phone/Fax

Practice location:
  • Phone: 910-848-0216
  • Fax: 910-848-0216
Mailing address:
  • Phone: 910-848-0216
  • Fax: 910-848-0216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberMNL047109
License Number StateNC

VIII. Authorized Official

Name: MRS. MARION WILSON CISSEL
Title or Position: OWNER
Credential: 12/07/46
Phone: 910-848-0216