Provider Demographics
NPI:1669124301
Name:SISCO, CRYSTALL M
Entity type:Individual
Prefix:MRS
First Name:CRYSTALL
Middle Name:M
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 1:13324 BURLEIGH ST
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-1961
Mailing Address - Country:US
Mailing Address - Phone:202-498-4460
Mailing Address - Fax:
Practice Address - Street 1:3300 PENNSYLVANIA AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-2408
Practice Address - Country:US
Practice Address - Phone:202-878-6626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-24
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLG200001469104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker