Provider Demographics
NPI:1760029128
Name:SIDA, ROSSANA
Entity Type:Individual
Prefix:
First Name:ROSSANA
Middle Name:
Last Name:SIDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ROSSANA
Other - Middle Name:
Other - Last Name:SIDA FARAG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:605 S BARRINGTON AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-4411
Mailing Address - Country:US
Mailing Address - Phone:323-633-6986
Mailing Address - Fax:
Practice Address - Street 1:11835 W OLYMPIC BLVD STE 820
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-5033
Practice Address - Country:US
Practice Address - Phone:323-633-6986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT116114106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist