MEDICARE: JUSTIN SIDES PSYD

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	6301017242	MI

General Provider Information

NPI Number	:	1104276690
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTIN SIDES PSYD

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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2016
Last Update Date	:	03/29/2025

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