Provider Demographics
NPI:1629142435
Name:SIEGEL, EMILY TARBET (PSYD)
Entity Type:Individual
Prefix:DR
First Name:EMILY
Middle Name:TARBET
Last Name:SIEGEL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:DR
Other - First Name:EMILY
Other - Middle Name:MERRILL
Other - Last Name:TARBET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:301 US ROUTE 1
Mailing Address - Street 2:BUILDING C
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9701
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:1577 CONGRESS ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2169
Practice Address - Country:US
Practice Address - Phone:207-662-1622
Practice Address - Fax:207-774-1814
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1280103TC0700X
RIPS00865103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME434615199Medicaid
ME001306501Medicare PIN
ME434615199Medicaid