Provider Demographics
NPI:1457850984
Name:SIECZKOWSKI, MARJOLEIN (LCSW)
Entity Type:Individual
Prefix:
First Name:MARJOLEIN
Middle Name:
Last Name:SIECZKOWSKI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 E ELM AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3261
Mailing Address - Country:US
Mailing Address - Phone:480-466-2428
Mailing Address - Fax:
Practice Address - Street 1:125 E ELM AVE STE 203
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3261
Practice Address - Country:US
Practice Address - Phone:480-466-2428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-10
Last Update Date:2018-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-169631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical