1942585674 NPI number — MICHELLE GRACE SIERRA-KWANDHAM LCSW

Table of content: MICHELLE GRACE SIERRA-KWANDHAM LCSW (NPI 1942585674)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942585674 NPI number — MICHELLE GRACE SIERRA-KWANDHAM LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIERRA-KWANDHAM
Provider First Name:
MICHELLE
Provider Middle Name:
GRACE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

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:
1942585674
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/25/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
194 MISSILE AVENUE MINOT AFB ND 58705-5024
Provider Second Line Business Mailing Address:
10 MISSILE AVE
Provider Business Mailing Address City Name:
MINO
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58705-5024
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-723-5633
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18TH MEDICAL GROUP
Provider Second Line Business Practice Location Address:
UNIT 5142
Provider Business Practice Location Address City Name:
APO
Provider Business Practice Location Address State Name:
AP
Provider Business Practice Location Address Postal Code:
96368-5142
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-630-4780
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/13/2011

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: 1041C0700X , with the licence number:  C008207 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 11078 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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