Provider Demographics
NPI:1396123774
Name:SISCO, SELMA A (LMFT)
Entity type:Individual
Prefix:
First Name:SELMA
Middle Name:A
Last Name:SISCO
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:SELMA
Other - Middle Name:A
Other - Last Name:SISCO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMFT
Mailing Address - Street 1:3 COUNTRY HILL RD
Mailing Address - Street 2:LEBANON
Mailing Address - City:LEBANON
Mailing Address - State:NJ
Mailing Address - Zip Code:08833-3022
Mailing Address - Country:US
Mailing Address - Phone:908-303-1174
Mailing Address - Fax:
Practice Address - Street 1:3 COUNTRY HILL RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:NJ
Practice Address - Zip Code:08833-3022
Practice Address - Country:US
Practice Address - Phone:908-303-1174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-18
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37F100173600106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist