Healthcare Provider Details

I. General information

NPI: 1104740984
Provider Name (Legal Business Name): MISS ALLIE GRACE SIERDSMA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 STANDIFORD AVE STE 12180
MODESTO CA
95350-6522
US

IV. Provider business mailing address

11545 ECHO LN
HANFORD CA
93230-6320
US

V. Phone/Fax

Practice location:
  • Phone: 855-832-6727
  • Fax:
Mailing address:
  • Phone: 559-836-1820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: