Provider Demographics
NPI:1205447471
Name:SISCO, KASEY DIANA
Entity type:Individual
Prefix:
First Name:KASEY
Middle Name:DIANA
Last Name:SISCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KASEY
Other - Middle Name:DIANA
Other - Last Name:OTTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1007 PARKWOOD DR APT B
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60432-3139
Mailing Address - Country:US
Mailing Address - Phone:708-271-5311
Mailing Address - Fax:
Practice Address - Street 1:9018 HERITAGE PKWY STE 600
Practice Address - Street 2:
Practice Address - City:WOODRIDGE
Practice Address - State:IL
Practice Address - Zip Code:60517-5139
Practice Address - Country:US
Practice Address - Phone:630-442-7662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-12
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist