Healthcare Provider Details

I. General information

NPI: 1285350827
Provider Name (Legal Business Name): CAREN BOUKALIS CISSE LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2022
Last Update Date: 10/17/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1489 BALTIMORE PIKE STE 250
SPRINGFIELD PA
19064-3974
US

IV. Provider business mailing address

1489 BALTIMORE PIKE STE 250
SPRINGFIELD PA
19064-3974
US

V. Phone/Fax

Practice location:
  • Phone: 610-544-2110
  • Fax:
Mailing address:
  • Phone: 610-544-2110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: