Provider Demographics
NPI:1710215454
Name:SIERRACOUNSELING & MEDIATION, LLC
Entity Type:Organization
Organization Name:SIERRACOUNSELING & MEDIATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SIERRA
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:618-398-6552
Mailing Address - Street 1:6609 W MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223-3025
Mailing Address - Country:US
Mailing Address - Phone:618-398-6552
Mailing Address - Fax:618-398-0075
Practice Address - Street 1:6609 W MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-3025
Practice Address - Country:US
Practice Address - Phone:618-398-6552
Practice Address - Fax:618-398-0075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-18
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL166.000561106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1639199854OtherINDIVIDUAL NPI