Provider Demographics
NPI:1356855902
Name:SIDHOM-YARBOROUGH, KATREEN (EDS, NCSP)
Entity Type:Individual
Prefix:
First Name:KATREEN
Middle Name:
Last Name:SIDHOM-YARBOROUGH
Suffix:
Gender:F
Credentials:EDS, NCSP
Other - Prefix:
Other - First Name:KATREEN
Other - Middle Name:
Other - Last Name:SIDHOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2201 THORNCRAG LN
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23112-4561
Mailing Address - Country:US
Mailing Address - Phone:804-201-3298
Mailing Address - Fax:
Practice Address - Street 1:2201 THORNCRAG LN
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23112-4561
Practice Address - Country:US
Practice Address - Phone:443-452-8571
Practice Address - Fax:443-452-8571
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-18
Last Update Date:2017-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAPPS-0601637103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool