Healthcare Provider Details

I. General information

NPI: 1083463228
Provider Name (Legal Business Name): PSYCH CISA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2024
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 N MAIN ST UNIT H
HILTON HEAD ISLAND SC
29926-6603
US

IV. Provider business mailing address

60 MAIN ST UNIT H
HILTON HEAD ISLAND SC
29926-6603
US

V. Phone/Fax

Practice location:
  • Phone: 843-384-4611
  • Fax:
Mailing address:
  • Phone: 843-384-4611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. CIBELE DO CARMO SANTOS
Title or Position: MENTAL HEALTH COUNSELOR
Credential: PHD, LPC, MDIV
Phone: 843-384-4611