Provider Demographics
NPI:1225198542
Name:SISTI, SHANA PORTNOY (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:SHANA
Middle Name:PORTNOY
Last Name:SISTI
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:MRS
Other - First Name:SHANA
Other - Middle Name:PORTNOY
Other - Last Name:SISTI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1691 THE ALAMEDA
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-2203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:398 S GREEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-3099
Practice Address - Country:US
Practice Address - Phone:831-724-7525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA87616106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA#44A5OtherPARENTS CENTER
CAZZZ91892ZOtherSANTA CRUZ COUNTY MEDICARE GROUP PTAN#