Provider Demographics
NPI:1790360683
Name:ONTIVEROS, SYDNEY ANDREA
Entity Type:Individual
Prefix:
First Name:SYDNEY
Middle Name:ANDREA
Last Name:ONTIVEROS
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 1:3370 E CRESTA CT APT 205
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92010-6560
Mailing Address - Country:US
Mailing Address - Phone:209-954-2047
Mailing Address - Fax:
Practice Address - Street 1:5870 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-8816
Practice Address - Country:US
Practice Address - Phone:760-539-5818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-12
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst