MEDICARE: SIDES PSYCHOLOGICAL CONSULTING, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist

General Provider Information

NPI Number	:	1043013667
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SIDES PSYCHOLOGICAL CONSULTING, LLC

Provider Business Mailing Address
First Line	:	9272 SHOREWAY DR
Second Line	:
City	:	WEST OLIVE
State	:	MI
Zip	:	49460-8866
Country	:	US
Telephone Number	:	616-886-9001
Fax Number	:

Provider Business Practice Location Address
First Line	:	9272 SHOREWAY DR
Second Line	:
City	:	WEST OLIVE
State	:	MI
Zip	:	49460-8866
Country	:	US
Telephone Number	:	616-886-9001
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JUSTIN DAVID SIDES
Credential	:	PSYD
Telephone Number	:	616-886-9001

Provider Enumeration Date	:	03/29/2025
Last Update Date	:	03/29/2025

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