Provider Demographics
NPI:1457801276
Name:SISCO, WILLIAM (PSYD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:
Last Name:SISCO
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 COTTAGEVIEW DR STE 103
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2373
Mailing Address - Country:US
Mailing Address - Phone:231-631-7517
Mailing Address - Fax:
Practice Address - Street 1:830 COTTAGEVIEW DR STE 103
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2373
Practice Address - Country:US
Practice Address - Phone:231-631-7517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-04
Last Update Date:2021-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810005386103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical