Provider Demographics
NPI:1689755936
Name:SIDENER, KATHLEEN DIANA (PT, CERT MDT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:DIANA
Last Name:SIDENER
Suffix:
Gender:F
Credentials:PT, CERT MDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 MCCABE DR STE 101
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-4815
Mailing Address - Country:US
Mailing Address - Phone:775-788-5599
Mailing Address - Fax:775-788-5598
Practice Address - Street 1:15 MCCABE DR STE 101
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-4815
Practice Address - Country:US
Practice Address - Phone:775-788-5599
Practice Address - Fax:775-788-5598
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0364174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV31779Medicare PIN