Provider Demographics
NPI:1992492490
Name:DILLARD, SIDRA EMMALINE
Entity type:Individual
Prefix:
First Name:SIDRA
Middle Name:EMMALINE
Last Name:DILLARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1827 E WASHINGTON AVE APT 406
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-5247
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1107 NE 45TH ST STE 315
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-4656
Practice Address - Country:US
Practice Address - Phone:206-785-1953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8583-125101YM0800X
WALH61406138101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health