Provider Demographics
NPI:1811005747
Name:SIEGEL, EDWARD M (PHD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:M
Last Name:SIEGEL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 JOHNSON STREET
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-1828
Mailing Address - Country:US
Mailing Address - Phone:505-983-3757
Mailing Address - Fax:505-982-3300
Practice Address - Street 1:301 JOHNSON STREET
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-1828
Practice Address - Country:US
Practice Address - Phone:505-983-3757
Practice Address - Fax:505-982-3300
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM188103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
N879OtherBCBS
201009233OtherPRESBYTERIAN HEALTH PLAN
2506607Medicare ID - Type Unspecified
201009233OtherPRESBYTERIAN HEALTH PLAN