Provider Demographics
NPI:1629168596
Name:SIEGEL, MARY ELIZABETH (PHD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:SIEGEL
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:363 OCEAN DR W
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-8222
Mailing Address - Country:US
Mailing Address - Phone:203-324-9996
Mailing Address - Fax:203-921-1565
Practice Address - Street 1:363 OCEAN DR W
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-8222
Practice Address - Country:US
Practice Address - Phone:203-324-9996
Practice Address - Fax:203-921-1565
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001450103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT620000286Medicare ID - Type UnspecifiedPSYCHOLOGIST