Provider Demographics
NPI:1497147516
Name:SISCO, KRISTINA LOUISE
Entity Type:Individual
Prefix:MRS
First Name:KRISTINA
Middle Name:LOUISE
Last Name:SISCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29163 SUNDIAL CIR
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-7362
Mailing Address - Country:US
Mailing Address - Phone:858-829-9838
Mailing Address - Fax:951-827-3202
Practice Address - Street 1:224 W GRAHAM AVE
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-3740
Practice Address - Country:US
Practice Address - Phone:951-318-1351
Practice Address - Fax:866-340-6736
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-26
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1806101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor