Provider Demographics
NPI:1831387562
Name:SIADAL, INGRID CHRISTINA (MED, MSW)
Entity type:Individual
Prefix:
First Name:INGRID
Middle Name:CHRISTINA
Last Name:SIADAL
Suffix:
Gender:F
Credentials:MED, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:182 SW ACADEMY ST
Mailing Address - Street 2:SUITE 304
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-1922
Mailing Address - Country:US
Mailing Address - Phone:503-623-9289
Mailing Address - Fax:503-831-1726
Practice Address - Street 1:182 SW ACADEMY ST
Practice Address - Street 2:SUITE 304
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-1922
Practice Address - Country:US
Practice Address - Phone:503-623-9289
Practice Address - Fax:503-831-1726
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORA25861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical