Provider Demographics
NPI:1689865081
Name:SIVESIND, JOHN ROY (EDD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROY
Last Name:SIVESIND
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 W BROAD AVE
Mailing Address - Street 2:
Mailing Address - City:FLANDREAU
Mailing Address - State:SD
Mailing Address - Zip Code:57028
Mailing Address - Country:US
Mailing Address - Phone:605-997-2640
Mailing Address - Fax:
Practice Address - Street 1:107 W BROAD AVE
Practice Address - Street 2:
Practice Address - City:FLANDREAU
Practice Address - State:SD
Practice Address - Zip Code:57028
Practice Address - Country:US
Practice Address - Phone:605-997-2640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD283103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5546010Medicaid