Provider Demographics
NPI:1821168501
Name:SIEGEL, ELLEN BETH (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:BETH
Last Name:SIEGEL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 NEHOIDEN RD
Mailing Address - Street 2:
Mailing Address - City:WABAN
Mailing Address - State:MA
Mailing Address - Zip Code:02468-1926
Mailing Address - Country:US
Mailing Address - Phone:617-826-9450
Mailing Address - Fax:617-722-4954
Practice Address - Street 1:187 MOUNT AUBURN ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-4863
Practice Address - Country:US
Practice Address - Phone:617-826-9450
Practice Address - Fax:617-722-4954
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7739103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110085068AMedicaid
MA1103210OtherNEIGHBORHOOD HEALTH PLAN
MAW06211OtherBLUE CROSS/BLUE SHIELD
MA1821168501OtherHARVARD PILGRIM HEALTHCARE