Provider Demographics
NPI:1578841953
Name:SIEDLER, KENNETH STEVEN (PSYD, MA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:STEVEN
Last Name:SIEDLER
Suffix:
Gender:M
Credentials:PSYD, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 N CARROLL AVE APT 1212
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-4803
Mailing Address - Country:US
Mailing Address - Phone:510-504-7224
Mailing Address - Fax:
Practice Address - Street 1:12801 N CENTRAL EXPY STE 1730
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-1872
Practice Address - Country:US
Practice Address - Phone:214-784-1785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-02
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program