Provider Demographics
NPI:1518473180
Name:SIEDENBURG, SANDRA MAY
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:MAY
Last Name:SIEDENBURG
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 1:28881 SHANNON CT APT 27
Mailing Address - Street 2:
Mailing Address - City:TEHACHAPI
Mailing Address - State:CA
Mailing Address - Zip Code:93561-5253
Mailing Address - Country:US
Mailing Address - Phone:661-675-7060
Mailing Address - Fax:
Practice Address - Street 1:28881 SHANNON CT APT 27
Practice Address - Street 2:
Practice Address - City:TEHACHAPI
Practice Address - State:CA
Practice Address - Zip Code:93561-5253
Practice Address - Country:US
Practice Address - Phone:661-675-7060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-19
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1281531017101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)