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General NPI Number Information
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NPI Number | 1104616531
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Entity Type | Organization
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Legal Business Name | CISCO COUNSELING LLC
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Dates
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Enumeration Date | 05/08/2025
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Last Update Date | 05/08/2025
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Provider Practice Location Address
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Address Line | 1504 S POPLAR ST
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City | CENTRALIA
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State | IL
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Zip | 62801-5172
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Country | US
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Telephone | 618-267-0305
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Fax |
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Provider Business Mailing Address
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Address Line | 1504 S POPLAR ST
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City | CENTRALIA
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State | IL
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Zip | 62801-5172
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Country | US
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Telephone | 618-267-0305
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MR. WASHINGTON DIXON CISCO
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Credential | MR
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Telephone | 618-267-0305
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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