Provider Demographics
NPI:1346624830
Name:UNDERWOOD, KISSA (LCDC)
Entity Type:Individual
Prefix:
First Name:KISSA
Middle Name:
Last Name:UNDERWOOD
Suffix:
Gender:F
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 WYOMING AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79903-3409
Mailing Address - Country:US
Mailing Address - Phone:915-779-4527
Mailing Address - Fax:915-779-3511
Practice Address - Street 1:1900 WYOMING AVE
Practice Address - Street 2:SUITE B
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79903-3409
Practice Address - Country:US
Practice Address - Phone:915-779-4527
Practice Address - Fax:915-779-3511
Is Sole Proprietor?:No
Enumeration Date:2015-07-14
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXLCDC 12944101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)