Provider Demographics
NPI:1801937800
Name:SISTI, MARK (PHD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:SISTI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 ARBOR RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11720-1405
Mailing Address - Country:US
Mailing Address - Phone:631-696-2896
Mailing Address - Fax:631-696-2896
Practice Address - Street 1:32 ARBOR RIDGE LN
Practice Address - Street 2:
Practice Address - City:SOUTH SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11720-1405
Practice Address - Country:US
Practice Address - Phone:631-696-2896
Practice Address - Fax:631-696-2896
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011538103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV94561Medicare ID - Type UnspecifiedPROVIDER #