Provider Demographics
NPI:1942585674
Name:SIERRA-KWANDHAM, MICHELLE GRACE (LCSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:GRACE
Last Name:SIERRA-KWANDHAM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:194 MISSILE AVENUE MINOT AFB ND 58705-5024
Mailing Address - Street 2:10 MISSILE AVE
Mailing Address - City:MINO
Mailing Address - State:ND
Mailing Address - Zip Code:58705-5024
Mailing Address - Country:US
Mailing Address - Phone:701-723-5633
Mailing Address - Fax:
Practice Address - Street 1:18TH MEDICAL GROUP
Practice Address - Street 2:UNIT 5142
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96368-5142
Practice Address - Country:US
Practice Address - Phone:315-630-4780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-13
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0082071041C0700X
SC110781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical