MEDICARE: MS. CYNTHIA CHITTUM LISSAU LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	0701002064	VA

General Provider Information

NPI Number	:	1871780361
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CYNTHIA CHITTUM LISSAU LPC

Provider Business Mailing Address
First Line	:	2603 LIVINGSTON RD SW
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24015-4037
Country	:	US
Telephone Number	:	540-293-1232
Fax Number	:

Provider Business Practice Location Address
First Line	:	2603 LIVINGSTON RD SW
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24015-4037
Country	:	US
Telephone Number	:	540-293-1232
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2007
Last Update Date	:	09/27/2007

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