Provider Demographics
NPI:1134288657
Name:CRISS, SALLY (LAC)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:CRISS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 PETALUMA AVE
Mailing Address - Street 2:SUITE 124
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-4277
Mailing Address - Country:US
Mailing Address - Phone:707-823-6565
Mailing Address - Fax:
Practice Address - Street 1:435 PETALUMA AVE
Practice Address - Street 2:SUITE 124
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4277
Practice Address - Country:US
Practice Address - Phone:707-823-6565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 8997171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist