Provider Demographics
NPI:1104372960
Name:SISSON, KEVIN LYN
Entity Type:Individual
Prefix:MS
First Name:KEVIN
Middle Name:LYN
Last Name:SISSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 LIMA RD
Mailing Address - Street 2:
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355-3290
Mailing Address - Country:US
Mailing Address - Phone:301-693-3525
Mailing Address - Fax:
Practice Address - Street 1:6 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:WESTERLY
Practice Address - State:RI
Practice Address - Zip Code:02891-3138
Practice Address - Country:US
Practice Address - Phone:301-693-3525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health