Provider Demographics
NPI:1265404636
Name:SISE, MARY THERESA (LCSW)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:THERESA
Last Name:SISE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:596 NEW LOUDON RD
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-4024
Mailing Address - Country:US
Mailing Address - Phone:518-785-8576
Mailing Address - Fax:
Practice Address - Street 1:596 NEW LOUDON RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-4024
Practice Address - Country:US
Practice Address - Phone:518-785-8576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR-0392151041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYIA0534Medicare ID - Type UnspecifiedPROVIDER