Healthcare Provider Details

I. General information

NPI: 1629756622
Provider Name (Legal Business Name): DEONDRAE TYSHAWN CISSE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2023
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1175 N GUIGNARD DR
SUMTER SC
29150-1519
US

IV. Provider business mailing address

1175 N GUIGNARD DR
SUMTER SC
29150-1519
US

V. Phone/Fax

Practice location:
  • Phone: 803-580-6511
  • Fax:
Mailing address:
  • Phone: 803-580-6511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: