Provider Demographics
NPI:1629756622
Name:CISSE, DEONDRAE TYSHAWN
Entity Type:Individual
Prefix:
First Name:DEONDRAE
Middle Name:TYSHAWN
Last Name:CISSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1175 N GUIGNARD DR
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-1519
Mailing Address - Country:US
Mailing Address - Phone:803-580-6511
Mailing Address - Fax:
Practice Address - Street 1:1175 N GUIGNARD DR
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-1519
Practice Address - Country:US
Practice Address - Phone:803-580-6511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging