Healthcare Provider Details

I. General information

NPI: 1770366965
Provider Name (Legal Business Name): ANNA AGNES SIDDALL T-LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2023
Last Update Date: 08/14/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

329 10TH AVE SE STE 301C
CEDAR RAPIDS IA
52401-2358
US

IV. Provider business mailing address

304 30TH ST SE
CEDAR RAPIDS IA
52403-1906
US

V. Phone/Fax

Practice location:
  • Phone: 319-329-9568
  • Fax:
Mailing address:
  • Phone: 319-329-9568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number119897
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: