Provider Demographics
NPI:1619434644
Name:KIESSIG, PRISCILLA ANNE (LCSW)
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:ANNE
Last Name:KIESSIG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 TESSA CT
Mailing Address - Street 2:
Mailing Address - City:TEMPLETON
Mailing Address - State:CA
Mailing Address - Zip Code:93465-3608
Mailing Address - Country:US
Mailing Address - Phone:805-400-3076
Mailing Address - Fax:
Practice Address - Street 1:5955 CAPISTRANO AVE STE G
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-7227
Practice Address - Country:US
Practice Address - Phone:805-400-3076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA872291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical