Provider Demographics
NPI:1609090844
Name:SISLER, BRETT ALAN (LCSW LICENSED CLINIC)
Entity Type:Individual
Prefix:MR
First Name:BRETT
Middle Name:ALAN
Last Name:SISLER
Suffix:
Gender:M
Credentials:LCSW LICENSED CLINIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 HORATIO BLVD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089
Mailing Address - Country:US
Mailing Address - Phone:847-520-5415
Mailing Address - Fax:847-816-9183
Practice Address - Street 1:114 W ROCKLAND RD
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048
Practice Address - Country:US
Practice Address - Phone:847-816-9180
Practice Address - Fax:847-816-9183
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
204596Medicare ID - Type Unspecified