Provider Demographics
NPI:1316572126
Name:SISCO, MCKENSIE (RBT)
Entity Type:Individual
Prefix:
First Name:MCKENSIE
Middle Name:
Last Name:SISCO
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4491 LONG PRAIRIE RD STE 300
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75028-1795
Mailing Address - Country:US
Mailing Address - Phone:469-687-9184
Mailing Address - Fax:
Practice Address - Street 1:4491 LONG PRAIRIE RD STE 300
Practice Address - Street 2:
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-1795
Practice Address - Country:US
Practice Address - Phone:469-687-9184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-12
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20-114465106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician