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General NPI Number Information
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NPI Number | 1023377561
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Entity Type | Individual
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Provider Name | KERSTIN MANDERSON SIDNEY LCSW
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Gender | Female
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Dates
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Enumeration Date | 05/03/2012
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Last Update Date | 01/17/2017
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Provider Practice Location Address
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Address Line | 1021 FREMONT AVE
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City | SOUTH LAKE TAHOE
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State | CA
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Zip | 96150-8136
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Country | US
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Telephone | 530-541-2445
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Fax | 530-541-0517
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Provider Business Mailing Address
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Address Line | PO BOX 13633
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City | SOUTH LAKE TAHOE
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State | CA
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Zip | 96151-3633
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Country | US
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Telephone | 949-302-8303
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | ASW23055
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | LCS29222
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License Number State | CA
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