Provider Demographics
NPI:1023377561
Name:SIDNEY, KERSTIN MANDERSON (LCSW)
Entity Type:Individual
Prefix:
First Name:KERSTIN
Middle Name:MANDERSON
Last Name:SIDNEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KERSTIN
Other - Middle Name:NICOLE
Other - Last Name:MANDERSON-SIDNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 13633
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96151-3633
Mailing Address - Country:US
Mailing Address - Phone:949-302-8303
Mailing Address - Fax:
Practice Address - Street 1:1021 FREMONT AVE
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-8136
Practice Address - Country:US
Practice Address - Phone:530-541-2445
Practice Address - Fax:530-541-0517
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-03
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW23055101YM0800X
CALCS29222101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health