Provider Demographics
NPI:1104276690
Name:SIDES, JUSTIN (PSYD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:SIDES
Suffix:
Gender:
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9272 SHOREWAY DR
Mailing Address - Street 2:
Mailing Address - City:WEST OLIVE
Mailing Address - State:MI
Mailing Address - Zip Code:49460-8866
Mailing Address - Country:US
Mailing Address - Phone:616-886-9001
Mailing Address - Fax:
Practice Address - Street 1:9272 SHOREWAY DR
Practice Address - Street 2:
Practice Address - City:WEST OLIVE
Practice Address - State:MI
Practice Address - Zip Code:49460-8866
Practice Address - Country:US
Practice Address - Phone:616-886-9001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-15
Last Update Date:2025-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301017242103T00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist