Provider Demographics
NPI:1639641137
Name:SISCO, PATRICE SELFRIDGE
Entity Type:Individual
Prefix:
First Name:PATRICE
Middle Name:SELFRIDGE
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 1:50243 HANGTREE LN # A
Mailing Address - Street 2:
Mailing Address - City:OAKHURST
Mailing Address - State:CA
Mailing Address - Zip Code:93644-9767
Mailing Address - Country:US
Mailing Address - Phone:559-917-8094
Mailing Address - Fax:
Practice Address - Street 1:50243 HANGTREE LN # A
Practice Address - Street 2:
Practice Address - City:OAKHURST
Practice Address - State:CA
Practice Address - Zip Code:93644-9767
Practice Address - Country:US
Practice Address - Phone:559-917-8094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-20
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst