Provider Demographics
NPI:1497494264
Name:SISTO, VICTORIA ROSE
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:ROSE
Last Name:SISTO
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 1:1256 S OXBOW WAY
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-7729
Mailing Address - Country:US
Mailing Address - Phone:972-742-4025
Mailing Address - Fax:
Practice Address - Street 1:2070 MCKENZIE RD STE C
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-0870
Practice Address - Country:US
Practice Address - Phone:470-750-7778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-31
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist