Provider Demographics
NPI:1417252842
Name:SIEGEL, IRIS (MS, BCBA)
Entity Type:Individual
Prefix:
First Name:IRIS
Middle Name:
Last Name:SIEGEL
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 KERR CANYON RD
Mailing Address - Street 2:
Mailing Address - City:COBDEN
Mailing Address - State:IL
Mailing Address - Zip Code:62920-3540
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:615 KERR CANYON RD
Practice Address - Street 2:
Practice Address - City:COBDEN
Practice Address - State:IL
Practice Address - Zip Code:62920-3540
Practice Address - Country:US
Practice Address - Phone:618-713-1154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-15
Last Update Date:2011-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-01-0446103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst