Provider Demographics
NPI:1437933306
Name:KWAST, SIERRA JODEE
Entity Type:Individual
Prefix:
First Name:SIERRA
Middle Name:JODEE
Last Name:KWAST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24568 N 144TH DR
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85387-7037
Mailing Address - Country:US
Mailing Address - Phone:623-512-5109
Mailing Address - Fax:
Practice Address - Street 1:24568 N 144TH DR
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85387-7037
Practice Address - Country:US
Practice Address - Phone:623-512-5109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-22
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC-22072101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health