Provider Demographics
NPI:1124165311
Name:SIADOUS, TYRENE MICHELLE (MFT)
Entity type:Individual
Prefix:
First Name:TYRENE
Middle Name:MICHELLE
Last Name:SIADOUS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 YUBA ST
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-1165
Mailing Address - Country:US
Mailing Address - Phone:530-710-8255
Mailing Address - Fax:
Practice Address - Street 1:1005 YUBA ST
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-1165
Practice Address - Country:US
Practice Address - Phone:530-710-8255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50120106H00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health