Provider Demographics
NPI:1942997341
Name:JOSEPH, SIDNEY ALLEN
Entity Type:Individual
Prefix:
First Name:SIDNEY
Middle Name:ALLEN
Last Name:JOSEPH
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 1:4646 W 122ND ST APT 107
Mailing Address - Street 2:
Mailing Address - City:ALSIP
Mailing Address - State:IL
Mailing Address - Zip Code:60803-2514
Mailing Address - Country:US
Mailing Address - Phone:773-991-6129
Mailing Address - Fax:
Practice Address - Street 1:4259 S BERKELEY AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653-3030
Practice Address - Country:US
Practice Address - Phone:773-268-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health