Provider Demographics
NPI:1942646807
Name:SIDWELL, DEAN ALLEN
Entity Type:Individual
Prefix:MR
First Name:DEAN
Middle Name:ALLEN
Last Name:SIDWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4930 BAJA COURT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115
Mailing Address - Country:US
Mailing Address - Phone:619-405-7410
Mailing Address - Fax:
Practice Address - Street 1:4930 BAJA CT
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-2230
Practice Address - Country:US
Practice Address - Phone:619-405-7410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-20
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA283771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical