Provider Demographics
NPI:1760202949
Name:SIDER, MIRANDA (MS, LCAT-P, ATR-P)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:SIDER
Suffix:
Gender:X
Credentials:MS, LCAT-P, ATR-P
Other - Prefix:
Other - First Name:MARLOWE
Other - Middle Name:
Other - Last Name:SIDER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:98 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580
Mailing Address - Country:US
Mailing Address - Phone:585-210-0150
Mailing Address - Fax:
Practice Address - Street 1:98 NORTH AVE
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:NY
Practice Address - Zip Code:14580-3193
Practice Address - Country:US
Practice Address - Phone:585-210-0150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-14
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP130927101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health