Provider Demographics
NPI:1154497972
Name:RISSELL, CHARLES A (MA,EDS,LPC)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:A
Last Name:RISSELL
Suffix:
Gender:M
Credentials:MA,EDS,LPC
Other - Prefix:
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Mailing Address - Street 1:CO PHROG SERVICES
Mailing Address - Street 2:PO BOX 40704
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81504
Mailing Address - Country:US
Mailing Address - Phone:970-245-6525
Mailing Address - Fax:970-245-6574
Practice Address - Street 1:2754 COMPASS DR
Practice Address - Street 2:SUITE 115
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81506-8714
Practice Address - Country:US
Practice Address - Phone:970-245-6525
Practice Address - Fax:970-245-6574
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO1312101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO081852Medicaid