Provider Demographics
NPI:1730656489
Name:SIEVENS, OTTO
Entity Type:Individual
Prefix:
First Name:OTTO
Middle Name:
Last Name:SIEVENS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1790 NATIONS DR
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-9164
Mailing Address - Country:US
Mailing Address - Phone:847-204-3587
Mailing Address - Fax:
Practice Address - Street 1:1790 NATIONS DR
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-9164
Practice Address - Country:US
Practice Address - Phone:847-204-3587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-31
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker