Provider Demographics
NPI:1700240272
Name:SIS, ADALID (LPC)
Entity Type:Individual
Prefix:
First Name:ADALID
Middle Name:
Last Name:SIS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:ADALID
Other - Middle Name:
Other - Last Name:ONTIVEROS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1011 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75766-3307
Mailing Address - Country:US
Mailing Address - Phone:903-586-5507
Mailing Address - Fax:903-586-4234
Practice Address - Street 1:3320 S LOOP 256
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-6984
Practice Address - Country:US
Practice Address - Phone:903-723-6136
Practice Address - Fax:903-586-4234
Is Sole Proprietor?:No
Enumeration Date:2016-04-11
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69638101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX69638OtherLPC LICENSE