Provider Demographics
NPI:1982193728
Name:SISCO, TIVOLI MIA
Entity Type:Individual
Prefix:
First Name:TIVOLI
Middle Name:MIA
Last Name:SISCO
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 1:21200 CHIQUITA WAY
Mailing Address - Street 2:
Mailing Address - City:SARATOGA
Mailing Address - State:CA
Mailing Address - Zip Code:95070-4259
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1950 ALAMEDA DE LAS PULGAS
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-1222
Practice Address - Country:US
Practice Address - Phone:650-573-3571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health