Provider Demographics
NPI:1720895055
Name:SISCO, EUGENE (CADC)
Entity type:Individual
Prefix:
First Name:EUGENE
Middle Name:
Last Name:SISCO
Suffix:
Gender:M
Credentials:CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2214 S MAYO TRL
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501-2297
Mailing Address - Country:US
Mailing Address - Phone:606-262-0451
Mailing Address - Fax:
Practice Address - Street 1:2214 S MAYO TRL
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-2297
Practice Address - Country:US
Practice Address - Phone:606-262-0451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-11
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY278123101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)