Provider Demographics
NPI:1063946929
Name:BISSELL, JOANNA LUCIA (LCSW, LCSW-C, LICSW)
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:LUCIA
Last Name:BISSELL
Suffix:
Gender:F
Credentials:LCSW, LCSW-C, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 PROSPECT AVE STE U
Mailing Address - Street 2:
Mailing Address - City:KIRKWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63122-6024
Mailing Address - Country:US
Mailing Address - Phone:314-690-5873
Mailing Address - Fax:314-677-3326
Practice Address - Street 1:140 PROSPECT AVE STE U
Practice Address - Street 2:
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-6024
Practice Address - Country:US
Practice Address - Phone:314-690-5873
Practice Address - Fax:314-677-3326
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-18
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD226281041C0700X
MO20180394841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490066029Medicaid