Provider Demographics
NPI:1891172540
Name:SIEGERT, MOLLY
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:SIEGERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4227 9TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-2018
Mailing Address - Country:US
Mailing Address - Phone:701-282-6561
Mailing Address - Fax:
Practice Address - Street 1:4227 9TH AVE SW
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-2018
Practice Address - Country:US
Practice Address - Phone:701-282-6561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-01
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND101YA0400X101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)