Provider Demographics
NPI:1962634196
Name:SIDER, LINDA M
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:M
Last Name:SIDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:M
Other - Last Name:PELICAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12371 HIGHWAY 90
Mailing Address - Street 2:SUITE D
Mailing Address - City:LULING
Mailing Address - State:LA
Mailing Address - Zip Code:70070-5114
Mailing Address - Country:US
Mailing Address - Phone:985-331-1001
Mailing Address - Fax:985-331-1005
Practice Address - Street 1:12371 HIGHWAY 90
Practice Address - Street 2:SUITE D
Practice Address - City:LULING
Practice Address - State:LA
Practice Address - Zip Code:70070-2371
Practice Address - Country:US
Practice Address - Phone:985-331-1001
Practice Address - Fax:985-331-1005
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-21
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA7161174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist