Provider Demographics
NPI:1023710282
Name:DUNHAM, SIBAO LYNELL
Entity type:Individual
Prefix:
First Name:SIBAO
Middle Name:LYNELL
Last Name:DUNHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SIBAO
Other - Middle Name:
Other - Last Name:SARGENT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5464 WHITLOCK RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21229-1020
Mailing Address - Country:US
Mailing Address - Phone:443-739-5242
Mailing Address - Fax:
Practice Address - Street 1:5464 WHITLOCK RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21229-1020
Practice Address - Country:US
Practice Address - Phone:443-739-5242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-21
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC15929101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty