Provider Demographics
NPI:1316717564
Name:KISALA, SYDNI
Entity type:Individual
Prefix:
First Name:SYDNI
Middle Name:
Last Name:KISALA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1639 YORK DR
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24073-1232
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1997 S MAIN ST STE 601
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-6606
Practice Address - Country:US
Practice Address - Phone:540-961-1230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-08
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242007633235Z00000X
VA2204001318235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist