Provider Demographics
NPI:1437575412
Name:SIEGEL, MYRON R (MSW)
Entity Type:Individual
Prefix:MR
First Name:MYRON
Middle Name:R
Last Name:SIEGEL
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3650 STANDISH AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-8113
Mailing Address - Country:US
Mailing Address - Phone:707-793-9030
Mailing Address - Fax:707-793-9234
Practice Address - Street 1:7345 BURTON AVE
Practice Address - Street 2:
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-3396
Practice Address - Country:US
Practice Address - Phone:707-793-9030
Practice Address - Fax:707-793-9234
Is Sole Proprietor?:No
Enumeration Date:2014-03-13
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW 289231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical