Provider Demographics
NPI:1790921963
Name:SISUNG, JAMES R II (PSYD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:R
Last Name:SISUNG
Suffix:II
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 CHASE AVE
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-4624
Mailing Address - Country:US
Mailing Address - Phone:207-872-4139
Mailing Address - Fax:
Practice Address - Street 1:30 CHASE AVE
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-4624
Practice Address - Country:US
Practice Address - Phone:207-872-4139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-18
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
METE1261103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist