=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770705469
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LINDA B. KISSELA MFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 344 PLACERVILLE DR SUITE 10
-----------------------------------------------------
City | PLACERVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95667-3920
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-626-5164
-----------------------------------------------------
Fax | 530-626-0670
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4377 CORDERO DR
-----------------------------------------------------
City | EL DORADO HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95762-7602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-933-7275
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFC29916
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------