Provider Demographics
NPI:1881429819
Name:SISK, JAMES RANDALL
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:RANDALL
Last Name:SISK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 W WICKENBURG WAY LOT 113
Mailing Address - Street 2:
Mailing Address - City:WICKENBURG
Mailing Address - State:AZ
Mailing Address - Zip Code:85390-1059
Mailing Address - Country:US
Mailing Address - Phone:928-776-0623
Mailing Address - Fax:
Practice Address - Street 1:2501 W WICKENBURG WAY LOT 113
Practice Address - Street 2:
Practice Address - City:WICKENBURG
Practice Address - State:AZ
Practice Address - Zip Code:85390-1059
Practice Address - Country:US
Practice Address - Phone:928-776-0623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22777101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty