Provider Demographics
NPI:1386795169
Name:SISSON, BERNARD RILEY (LCSW)
Entity type:Individual
Prefix:MR
First Name:BERNARD
Middle Name:RILEY
Last Name:SISSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1779 ELLIS HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850
Mailing Address - Country:US
Mailing Address - Phone:607-539-6218
Mailing Address - Fax:
Practice Address - Street 1:313 N AURORA ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-4201
Practice Address - Country:US
Practice Address - Phone:607-280-8340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0396501104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker