Provider Demographics
NPI:1467579334
Name:SISTAK, COURTNEY (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:SISTAK
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2487 S GILBERT RD STE 106-134
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-2805
Mailing Address - Country:US
Mailing Address - Phone:480-452-9365
Mailing Address - Fax:
Practice Address - Street 1:1090 S GILBERT RD STE 106-153
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-3438
Practice Address - Country:US
Practice Address - Phone:602-345-1785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP4767235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist