Provider Demographics
NPI:1629645155
Name:IVY SIEJA, LAUREN MARIE (LCSW)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:MARIE
Last Name:IVY SIEJA
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 1:620 MR HENRYS DR
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-2646
Mailing Address - Country:US
Mailing Address - Phone:936-645-1090
Mailing Address - Fax:
Practice Address - Street 1:518 E HOSPITAL ST
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75961-5239
Practice Address - Country:US
Practice Address - Phone:936-645-1090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX598571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty