Provider Demographics
NPI:1104357748
Name:SIEGEL, KASEY BLAIR (PHD)
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:BLAIR
Last Name:SIEGEL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KASEY
Other - Middle Name:
Other - Last Name:ROTHKOPF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:121 KENT RD
Mailing Address - Street 2:
Mailing Address - City:TENAFLY
Mailing Address - State:NJ
Mailing Address - Zip Code:07670-2305
Mailing Address - Country:US
Mailing Address - Phone:617-515-7748
Mailing Address - Fax:
Practice Address - Street 1:901 5TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4157
Practice Address - Country:US
Practice Address - Phone:646-351-0220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-24
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY024810103TC0700X
NJ35S100695900103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program