Provider Demographics
NPI:1295892750
Name:HISSINK, CATHERINE M (MS)
Entity type:Individual
Prefix:
First Name:CATHERINE
Middle Name:M
Last Name:HISSINK
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W CHERRY ST
Mailing Address - Street 2:P. O. BOX 125
Mailing Address - City:NEVADA
Mailing Address - State:MO
Mailing Address - Zip Code:64772-2202
Mailing Address - Country:US
Mailing Address - Phone:417-667-4230
Mailing Address - Fax:417-667-7607
Practice Address - Street 1:300 W CHERRY ST
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:MO
Practice Address - Zip Code:64772-2202
Practice Address - Country:US
Practice Address - Phone:417-667-4230
Practice Address - Fax:417-667-7607
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO01351103T00000X
MOPY01351320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO493314306Medicaid
MO20591015OtherBLUE CROSS OF WESTERN MO