Provider Demographics
NPI:1265741805
Name:KISSELL, JUANITA M (MA, LPC, NCC, CCMHC)
Entity type:Individual
Prefix:
First Name:JUANITA
Middle Name:M
Last Name:KISSELL
Suffix:
Gender:F
Credentials:MA, LPC, NCC, CCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 BIRCH LN
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:TN
Mailing Address - Zip Code:37148-6027
Mailing Address - Country:US
Mailing Address - Phone:615-878-4058
Mailing Address - Fax:
Practice Address - Street 1:1003 BIRCH LN
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TN
Practice Address - Zip Code:37148-6027
Practice Address - Country:US
Practice Address - Phone:615-878-4058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-30
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLPC00545101YP2500X
TNLPC2686101YM0800X
KYLPCC1290101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional