Provider Demographics
NPI:1457597692
Name:SISKO, SUSAN E (LPC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:SISKO
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:419 E 7TH ST STE 207
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-2676
Mailing Address - Country:US
Mailing Address - Phone:541-296-5452
Mailing Address - Fax:541-296-4792
Practice Address - Street 1:419 E 7TH ST STE 207
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-2676
Practice Address - Country:US
Practice Address - Phone:541-296-5452
Practice Address - Fax:541-296-4792
Is Sole Proprietor?:No
Enumeration Date:2008-12-17
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC2188101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR139670Medicaid