Provider Demographics
NPI:1275650749
Name:SIDEMAN, LAWRENCE MARK (PHD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:MARK
Last Name:SIDEMAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10269 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-1051
Mailing Address - Country:US
Mailing Address - Phone:602-677-1206
Mailing Address - Fax:
Practice Address - Street 1:10269 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-1051
Practice Address - Country:US
Practice Address - Phone:602-677-1206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10540101YA0400X
AZ11790101YP2500X
AZ3015103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical