Provider Demographics
NPI:1730664145
Name:SIDERS, CONNIE FRANCES
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:FRANCES
Last Name:SIDERS
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 1:1528 NW 5TH ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1844
Mailing Address - Country:US
Mailing Address - Phone:765-200-6838
Mailing Address - Fax:
Practice Address - Street 1:1528 NW 5TH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1844
Practice Address - Country:US
Practice Address - Phone:765-200-6838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-02
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INCII2044101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)