Healthcare Provider Details

I. General information

NPI: 1225678071
Provider Name (Legal Business Name): MELISSA MARIE SISCO PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2020
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 W 4TH ST STE 207
CHARLOTTE NC
28202-1545
US

IV. Provider business mailing address

227 W 4TH ST STE 207
CHARLOTTE NC
28202-1545
US

V. Phone/Fax

Practice location:
  • Phone: 704-292-6020
  • Fax: 866-569-6995
Mailing address:
  • Phone: 704-292-6020
  • Fax: 866-569-6995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number103360
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: