Provider Demographics
NPI:1043938707
Name:SIEKIERSKI, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SIEKIERSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:671 BLACKHAWK DR
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:IL
Mailing Address - Zip Code:60510-1198
Mailing Address - Country:US
Mailing Address - Phone:630-205-0444
Mailing Address - Fax:
Practice Address - Street 1:201 HOUSTON ST
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:IL
Practice Address - Zip Code:60510-1960
Practice Address - Country:US
Practice Address - Phone:847-306-5461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0107281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical