Provider Demographics
NPI:1306119466
Name:SIDEROFF, STEPHEN I (PHD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:I
Last Name:SIDEROFF
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 16TH ST STE 210
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-1240
Mailing Address - Country:US
Mailing Address - Phone:310-828-1113
Mailing Address - Fax:310-828-9543
Practice Address - Street 1:1245 16TH ST STE 210
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1240
Practice Address - Country:US
Practice Address - Phone:310-828-1113
Practice Address - Fax:310-828-9543
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-20
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5777103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical