Provider Demographics
NPI:1841412079
Name:SISK, KIMBERLY
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:
Last Name:SISK
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 1:10956 MASSASOIT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60415-2417
Mailing Address - Country:US
Mailing Address - Phone:708-499-0409
Mailing Address - Fax:
Practice Address - Street 1:10956 MASSASOIT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-2417
Practice Address - Country:US
Practice Address - Phone:708-499-0409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3008466782001Medicaid