Provider Demographics
NPI:1497459242
Name:WALLENTINE, SYDNEE ZAYTEL
Entity type:Individual
Prefix:
First Name:SYDNEE
Middle Name:ZAYTEL
Last Name:WALLENTINE
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 1:5202 LUCKY AVE APT A4
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-2395
Mailing Address - Country:US
Mailing Address - Phone:801-786-9604
Mailing Address - Fax:
Practice Address - Street 1:1090 HILINE RD
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2902
Practice Address - Country:US
Practice Address - Phone:208-235-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-27
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
ID106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist