=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801937800
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK SISTI PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 32 ARBOR RIDGE LN
-----------------------------------------------------
City | SOUTH SETAUKET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11720-1405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-696-2896
-----------------------------------------------------
Fax | 631-696-2896
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 32 ARBOR RIDGE LN
-----------------------------------------------------
City | SOUTH SETAUKET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11720-1405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-696-2896
-----------------------------------------------------
Fax | 631-696-2896
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 011538
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------