Provider Demographics
NPI:1225300759
Name:CISSELL, KELLY ANN
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:CISSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 MUNICIPAL DR
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:MO
Mailing Address - Zip Code:63010-1012
Mailing Address - Country:US
Mailing Address - Phone:636-296-6206
Mailing Address - Fax:636-296-0102
Practice Address - Street 1:227 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-1952
Practice Address - Country:US
Practice Address - Phone:636-931-2700
Practice Address - Fax:636-296-1961
Is Sole Proprietor?:No
Enumeration Date:2012-01-30
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007035677106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist