Provider Demographics
NPI:1790779726
Name:SIDEREAS, CAROLYN W (LPC)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:W
Last Name:SIDEREAS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2237 RIDGE RD
Mailing Address - Street 2:STE 101
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-5164
Mailing Address - Country:US
Mailing Address - Phone:972-771-3969
Mailing Address - Fax:972-771-8258
Practice Address - Street 1:2237 RIDGE RD
Practice Address - Street 2:STE 101
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-5164
Practice Address - Country:US
Practice Address - Phone:972-771-3969
Practice Address - Fax:972-771-8258
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17879101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX17879OtherLPC LICENSE#