Provider Demographics
NPI:1972159440
Name:SISSELL, MARK EDWARD
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:EDWARD
Last Name:SISSELL
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 1:8180 19 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SAND LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49343-9455
Mailing Address - Country:US
Mailing Address - Phone:616-696-2304
Mailing Address - Fax:616-696-1713
Practice Address - Street 1:8180 19 MILE RD
Practice Address - Street 2:
Practice Address - City:SAND LAKE
Practice Address - State:MI
Practice Address - Zip Code:49343-9455
Practice Address - Country:US
Practice Address - Phone:616-696-2304
Practice Address - Fax:616-696-1713
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-12
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAL410007118253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency