Provider Demographics
NPI:1649753344
Name:SISK, DORIS TRINA' (LICSW)
Entity Type:Individual
Prefix:
First Name:DORIS
Middle Name:TRINA'
Last Name:SISK
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:LYSTER ARMY HEALTH CLINIC
Mailing Address - Street 2:301 ANDREWS AVE
Mailing Address - City:FORT RUCKER
Mailing Address - State:AL
Mailing Address - Zip Code:36362-5333
Mailing Address - Country:US
Mailing Address - Phone:334-255-7028
Mailing Address - Fax:334-255-7710
Practice Address - Street 1:LYSTER ARMY HEALTH CLINIC
Practice Address - Street 2:301 ANDREWS AVE
Practice Address - City:FORT RUCKER
Practice Address - State:AL
Practice Address - Zip Code:36362
Practice Address - Country:US
Practice Address - Phone:334-255-7028
Practice Address - Fax:334-255-7710
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-10
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4125C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical