Provider Demographics
NPI:1417245366
Name:SIDON, KRISTINE P (OT)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:P
Last Name:SIDON
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 WALBERTA RD
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13219-2214
Mailing Address - Country:US
Mailing Address - Phone:315-426-3200
Mailing Address - Fax:
Practice Address - Street 1:400 WALBERTA RD
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13219-2214
Practice Address - Country:US
Practice Address - Phone:315-426-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-13
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01366623Medicaid