Basic Information
| Provider Information | |||||||||
| NPI: | 1851515613 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SISTI | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | MATTHEW | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 EMELINE AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950601976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314544170 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1400 EMELINE AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950601976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314544170 | ||||||||
| FaxNumber: | 8314544663 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2007 | ||||||||
| LastUpdateDate: | 08/15/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 43851 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | ZZZ91891Z | 01 | CA | SANTA CRUZ COUNTY MEDICARE GOUP PTAN#S | OTHER | FHC 70042F | 01 | CA | SANTA CRUZ COUNTY CA - MEDI-CAL SITE#S | OTHER | LMFT 43851 | 01 | CA | PROFESSIONAL LICENSE# | OTHER | ZZZ91892Z | 01 | CA | SANTA CRUZ COUNTY MEDICARE GOUP PTAN#S | OTHER | FHC 70044F | 01 | CA | SANTA CRUZ COUNTY CA - MEDI-CAL SITE#S | OTHER | ZZZ92069Z | 01 | CA | SANTA CRUZ COUNTY MEDICARE GOUP PTAN#S | OTHER |