Provider Demographics
NPI:1861025165
Name:STILES, CISSY JO
Entity Type:Individual
Prefix:
First Name:CISSY
Middle Name:JO
Last Name:STILES
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 1:2101 W MACARTHUR RD LOT 824
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67217-6027
Mailing Address - Country:US
Mailing Address - Phone:316-841-8301
Mailing Address - Fax:
Practice Address - Street 1:700 N MARKET ST STE A
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-3530
Practice Address - Country:US
Practice Address - Phone:316-201-6047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-15
Last Update Date:2020-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS3130106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist