Provider Demographics
NPI:1154335495
Name:SIDBERRY, GRACE ELIZABETH (PHD)
Entity type:Individual
Prefix:DR
First Name:GRACE
Middle Name:ELIZABETH
Last Name:SIDBERRY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 S PINE ISLAND RD
Mailing Address - Street 2:SUITE 227
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-2673
Mailing Address - Country:US
Mailing Address - Phone:954-382-4889
Mailing Address - Fax:954-382-4884
Practice Address - Street 1:300 S PINE ISLAND RD
Practice Address - Street 2:SUITE 227
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-2673
Practice Address - Country:US
Practice Address - Phone:954-382-4889
Practice Address - Fax:954-382-4884
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-29
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 6164103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSIDBGRACOtherCORPHEALTH PROVIDER #
FL65-0991291OtherTRICARE
FLSIDBGRACOtherCORPHEALTH PROVIDER #