Provider Demographics
NPI:1972744639
Name:KISSICK, CHARLES MICHAEL (LADC, LPC, ICAADC)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MICHAEL
Last Name:KISSICK
Suffix:
Gender:M
Credentials:LADC, LPC, ICAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 E CHARTER OAK RD
Mailing Address - Street 2:
Mailing Address - City:GUTHRIE
Mailing Address - State:OK
Mailing Address - Zip Code:73044-9350
Mailing Address - Country:US
Mailing Address - Phone:405-466-8155
Mailing Address - Fax:866-390-5668
Practice Address - Street 1:4000 E CHARTER OAK RD
Practice Address - Street 2:
Practice Address - City:GUTHRIE
Practice Address - State:OK
Practice Address - Zip Code:73044-9350
Practice Address - Country:US
Practice Address - Phone:405-466-8155
Practice Address - Fax:405-390-5668
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-10
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK844101YA0400X
OKLPC04707101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)