Healthcare Provider Details

I. General information

NPI: 1396123774
Provider Name (Legal Business Name): SELMA A SISCO LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SELMA A SISCO LMFT

II. Dates (important events)

Enumeration Date: 05/18/2015
Last Update Date: 05/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 COUNTRY HILL RD
LEBANON NJ
08833-3022
US

IV. Provider business mailing address

3 COUNTRY HILL RD LEBANON
LEBANON NJ
08833-3022
US

V. Phone/Fax

Practice location:
  • Phone: 908-303-1174
  • Fax:
Mailing address:
  • Phone: 908-303-1174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number37F100173600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: