MEDICARE: MR. THEODORE WALTER SIOK

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	175T00000X	Peer Specialist	MPSS-CJMEFU	CA

General Provider Information

NPI Number	:	1558212720
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. THEODORE WALTER SIOK

Provider Business Mailing Address
First Line	:	1422 6TH ST APT 305
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90401-2545
Country	:	US
Telephone Number	:	310-913-8929
Fax Number	:

Provider Business Practice Location Address
First Line	:	1422 6TH ST APT 305
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90401-2545
Country	:	US
Telephone Number	:	310-913-8929
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/04/2026
Last Update Date	:	02/04/2026

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