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General NPI Number Information
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NPI Number | 1386795169
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Entity Type | Individual
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Provider Name | BERNARD RILEY SISSON LCSW
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Gender | Male
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Dates
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Enumeration Date | 01/16/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 313 N AURORA ST
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City | ITHACA
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State | NY
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Zip | 14850-4201
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Country | US
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Telephone | 607-280-8340
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Fax |
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Provider Business Mailing Address
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Address Line | 1779 ELLIS HOLLOW RD
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City | ITHACA
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State | NY
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Zip | 14850
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Country | US
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Telephone | 607-539-6218
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | R0396501
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License Number State | NY
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