Provider Demographics
NPI:1851515613
Name:SISTI, RYAN MATTHEW (LMFT)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:MATTHEW
Last Name:SISTI
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 EMELINE AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-1976
Mailing Address - Country:US
Mailing Address - Phone:831-454-4170
Mailing Address - Fax:
Practice Address - Street 1:1400 EMELINE AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-1976
Practice Address - Country:US
Practice Address - Phone:831-454-4170
Practice Address - Fax:831-454-4663
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43851106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ91891ZOtherSANTA CRUZ COUNTY MEDICARE GOUP PTAN#S
CAFHC 70042FOtherSANTA CRUZ COUNTY CA - MEDI-CAL SITE#S
CALMFT 43851OtherPROFESSIONAL LICENSE#
CAZZZ91892ZOtherSANTA CRUZ COUNTY MEDICARE GOUP PTAN#S
CAFHC 70044FOtherSANTA CRUZ COUNTY CA - MEDI-CAL SITE#S
CAZZZ92069ZOtherSANTA CRUZ COUNTY MEDICARE GOUP PTAN#S