Provider Demographics
NPI:1659403731
Name:SIDDOWAY, NICOLE DENISE (MA, LPC, CAC II)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:DENISE
Last Name:SIDDOWAY
Suffix:
Gender:F
Credentials:MA, LPC, CAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 E 34TH ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-3924
Mailing Address - Country:US
Mailing Address - Phone:417-347-7500
Mailing Address - Fax:417-347-7508
Practice Address - Street 1:530 E 34TH ST
Practice Address - Street 2:SUITE 102
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3924
Practice Address - Country:US
Practice Address - Phone:417-347-7500
Practice Address - Fax:417-347-7508
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007035690101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO497011205Medicaid