Healthcare Provider Details

I. General information

NPI: 1093535098
Provider Name (Legal Business Name): SANTIAGO SEDILLO LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2024
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 W ATKINS AVE
RIDGECREST CA
93555-2501
US

IV. Provider business mailing address

PO BOX 9190
MAMMOTH LAKES CA
93546-9161
US

V. Phone/Fax

Practice location:
  • Phone: 760-709-0262
  • Fax:
Mailing address:
  • Phone: 760-709-0262
  • Fax: 760-923-6816

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number164566
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: