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General NPI Number Information
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NPI Number | 1366000291
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Entity Type | Individual
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Provider Name | CHEYENNE AUTUMN HISSONG
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Gender | Female
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Dates
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Enumeration Date | 06/05/2019
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Last Update Date | 02/28/2025
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Provider Practice Location Address
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Address Line | 330 25TH STREET
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City | MOREHEAD
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State | KY
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Zip | 40351
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Country | US
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Telephone | 866-233-1955
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Fax |
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Provider Business Mailing Address
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Address Line | 1939 S DIVISION AVE
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City | GRAND RAPIDS
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State | MI
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Zip | 49507
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Country | US
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Telephone | 616-247-3815
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 6801104291
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License Number State | MI
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