Provider Demographics
NPI:1184151706
Name:SIDHU, MANJIT
Entity type:Individual
Prefix:
First Name:MANJIT
Middle Name:
Last Name:SIDHU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1446 HIDDEN RANCH DR
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-4567
Mailing Address - Country:US
Mailing Address - Phone:805-813-6933
Mailing Address - Fax:
Practice Address - Street 1:13440 VENTURA BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423-6158
Practice Address - Country:US
Practice Address - Phone:818-442-0921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-13
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-16-14618106S00000X
CA1-18-29392103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician