Provider Demographics
NPI:1629814686
Name:SOMBERG, SIDNEY HUNTER (LGPC)
Entity type:Individual
Prefix:
First Name:SIDNEY
Middle Name:HUNTER
Last Name:SOMBERG
Suffix:
Gender:F
Credentials:LGPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17530 LAKE MELFORD AVE APT 2053
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20715-4530
Mailing Address - Country:US
Mailing Address - Phone:608-906-2915
Mailing Address - Fax:
Practice Address - Street 1:770 RITCHIE HWY STE W16
Practice Address - Street 2:
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146-4158
Practice Address - Country:US
Practice Address - Phone:443-286-3578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP15259101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD11318681170Medicaid