Provider Demographics
NPI:1578808499
Name:KISSELLE, CORRINE LYNN (MED, PCC)
Entity Type:Individual
Prefix:MRS
First Name:CORRINE
Middle Name:LYNN
Last Name:KISSELLE
Suffix:
Gender:F
Credentials:MED, PCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:192 FOREST HILL DR
Mailing Address - Street 2:
Mailing Address - City:AVON LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44012-1744
Mailing Address - Country:US
Mailing Address - Phone:440-315-4695
Mailing Address - Fax:
Practice Address - Street 1:24800 HIGHPOINT RD
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-6052
Practice Address - Country:US
Practice Address - Phone:216-831-6611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-04
Last Update Date:2012-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE.0900196101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional