MEDICARE: MRS. CAROLYN W SIDEREAS LPC

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	101YP2500X	Professional Counselor	17879	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	17879	OTHER	TX	LPC LICENSE#

General Provider Information

NPI Number	:	1790779726
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CAROLYN W SIDEREAS LPC

Provider Business Mailing Address
First Line	:	2237 RIDGE RD
Second Line	:	STE 101
City	:	ROCKWALL
State	:	TX
Zip	:	75087-5164
Country	:	US
Telephone Number	:	972-771-3969
Fax Number	:	972-771-8258

Provider Business Practice Location Address
First Line	:	2237 RIDGE RD
Second Line	:	STE 101
City	:	ROCKWALL
State	:	TX
Zip	:	75087-5164
Country	:	US
Telephone Number	:	972-771-3969
Fax Number	:	972-771-8258

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

Provider Enumeration Date	:	09/06/2005
Last Update Date	:	07/08/2007

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