Provider Demographics
NPI:1851830582
Name:KELLI SIECZKOWSKI, PLLC
Entity Type:Organization
Organization Name:KELLI SIECZKOWSKI, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SIECZKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:480-630-0613
Mailing Address - Street 1:2469 W ZEPHER AVE
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-2543
Mailing Address - Country:US
Mailing Address - Phone:928-225-9585
Mailing Address - Fax:
Practice Address - Street 1:1930 S ALMA SCHOOL RD STE D202
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-3045
Practice Address - Country:US
Practice Address - Phone:480-630-0316
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-14
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW10655251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1740459460Medicare PIN