Provider Demographics
NPI:1114449865
Name:SISCO, WILLIAM MICHAEL (MA, MS, OTRL)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:MICHAEL
Last Name:SISCO
Suffix:
Gender:M
Credentials:MA, MS, OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 WELLSPRING DR
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-8737
Mailing Address - Country:US
Mailing Address - Phone:517-331-4388
Mailing Address - Fax:
Practice Address - Street 1:2222 SULLIVAN TRAIL
Practice Address - Street 2:WESTON GROUP
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18040-7958
Practice Address - Country:US
Practice Address - Phone:843-347-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-14
Last Update Date:2017-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4824225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist