Provider Demographics
NPI:1083463228
Name:PSYCH CISA LLC
Entity type:Organization
Organization Name:PSYCH CISA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH COUNSELOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CIBELE
Authorized Official - Middle Name:DO CARMO
Authorized Official - Last Name:SANTOS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, MDIV
Authorized Official - Phone:843-384-4611
Mailing Address - Street 1:77 CYPRESS MARSH DR
Mailing Address - Street 2:
Mailing Address - City:HILTON HEAD ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29926-2563
Mailing Address - Country:US
Mailing Address - Phone:843-384-4611
Mailing Address - Fax:
Practice Address - Street 1:60 N MAIN ST UNIT H
Practice Address - Street 2:
Practice Address - City:HILTON HEAD ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29926-6603
Practice Address - Country:US
Practice Address - Phone:843-384-4611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-17
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Single Specialty