Provider Demographics
NPI:1679714760
Name:SISCO, AJA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AJA
Middle Name:
Last Name:SISCO
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 RYBKA RD
Mailing Address - Street 2:PO BOX 60
Mailing Address - City:STUYVESANT FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12174-7708
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:65 RYBKA RD
Practice Address - Street 2:
Practice Address - City:STUYVESANT FALLS
Practice Address - State:NY
Practice Address - Zip Code:12174-7708
Practice Address - Country:US
Practice Address - Phone:845-417-4393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-18
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018261235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist