Provider Demographics
NPI:1699399774
Name:KISNER, SAMUEL E II
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:E
Last Name:KISNER
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1966 E 84TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44103-4264
Mailing Address - Country:US
Mailing Address - Phone:216-262-9651
Mailing Address - Fax:
Practice Address - Street 1:17325 EUCLID AVE STE 4103
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44112-1262
Practice Address - Country:US
Practice Address - Phone:216-232-5455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-03
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
OHC.2103203101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No251B00000XAgenciesCase Management