Provider Demographics
NPI:1982845053
Name:SISSOM, CYNTHIA LYNN (LADC)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:LYNN
Last Name:SISSOM
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 927
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74067-0927
Mailing Address - Country:US
Mailing Address - Phone:918-227-9890
Mailing Address - Fax:
Practice Address - Street 1:316 E LEE AVE
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-4306
Practice Address - Country:US
Practice Address - Phone:918-227-9890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-18
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK669101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)