Provider Demographics
NPI:1770906760
Name:SISSON, KELLY (LICSW)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:SISSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:BOYCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 155
Mailing Address - Street 2:
Mailing Address - City:ZEELAND
Mailing Address - State:ND
Mailing Address - Zip Code:58581-0155
Mailing Address - Country:US
Mailing Address - Phone:701-595-5789
Mailing Address - Fax:
Practice Address - Street 1:407 4TH AVE SW
Practice Address - Street 2:
Practice Address - City:ZEELAND
Practice Address - State:ND
Practice Address - Zip Code:58581-4047
Practice Address - Country:US
Practice Address - Phone:701-595-5789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-27
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490164321041C0700X
ND49781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND143053Medicaid
NDN722896Medicare PIN