Provider Demographics
NPI:1770705469
Name:KISSELA, LINDA B (MFT)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:B
Last Name:KISSELA
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4377 CORDERO DR
Mailing Address - Street 2:
Mailing Address - City:EL DORADO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:95762-7602
Mailing Address - Country:US
Mailing Address - Phone:916-933-7275
Mailing Address - Fax:
Practice Address - Street 1:344 PLACERVILLE DR
Practice Address - Street 2:SUITE 10
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-3920
Practice Address - Country:US
Practice Address - Phone:530-626-5164
Practice Address - Fax:530-626-0670
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC29916106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist