Provider Demographics
NPI:1700122165
Name:SISCO, CHERYL K (BS CAC II)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:K
Last Name:SISCO
Suffix:
Gender:F
Credentials:BS CAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6860 W MISSISSIPPI AVE APT D
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80226-4500
Mailing Address - Country:US
Mailing Address - Phone:303-975-1748
Mailing Address - Fax:
Practice Address - Street 1:6860 W MISSISSIPPI AVE UNIT D
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80226
Practice Address - Country:US
Practice Address - Phone:303-975-1748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-12
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO320800000X
324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility