MEDICARE: AYANNA TAMASHA SIDLE

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	101Y00000X	Counselor
2	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1972195477
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AYANNA TAMASHA SIDLE

Provider Business Mailing Address
First Line	:	2601 WOODLAND PARK DR APT 1204
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77077-6163
Country	:	US
Telephone Number	:	832-671-3362
Fax Number	:

Provider Business Practice Location Address
First Line	:	2601 WOODLAND PARK DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77077-6161
Country	:	US
Telephone Number	:	832-671-3362
Fax Number	:

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

Provider Enumeration Date	:	02/05/2021
Last Update Date	:	02/05/2021

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