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General NPI Number Information
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NPI Number | 1508039140
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Entity Type | Organization
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Legal Business Name | CISSELSALTERNATIVE
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Dates
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Enumeration Date | 04/03/2008
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Last Update Date | 04/08/2008
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Provider Practice Location Address
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Address Line | 126 DAVENPORT DR
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City | RAEFORD
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State | NC
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Zip | 28376-5425
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Country | US
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Telephone | 910-848-0216
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Fax | 910-848-0216
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Provider Business Mailing Address
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Address Line | 126 DAVENPORT DR
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City | RAEFORD
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State | NC
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Zip | 28376-5425
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Country | US
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Telephone | 910-848-0216
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Fax | 910-848-0216
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Authorized Official
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Title or Position | OWNER
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Name | MRS. MARION WILSON CISSEL
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Credential | 12/07/46
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Telephone | 910-848-0216
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | MNL047109
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License Number State | NC
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