1871075200 NPI number — MR. ALAN GREGORY SIDES LLMSW-CLINICAL

Table of content: MR. ALAN GREGORY SIDES LLMSW-CLINICAL (NPI 1871075200)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871075200 NPI number — MR. ALAN GREGORY SIDES LLMSW-CLINICAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIDES
Provider First Name:
ALAN
Provider Middle Name:
GREGORY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LLMSW-CLINICAL
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871075200
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/03/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23345 REDMAN CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROWNSTOWN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48183
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-771-0593
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 S MONROE ST STE 205
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48161-2469
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-240-3850
Provider Business Practice Location Address Fax Number:
734-240-3863
Provider Enumeration Date:
09/01/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 6801104489 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com