Provider Demographics
NPI:1205938933
Name:SIEGFRIED, MARY KATHLEEN (LMT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHLEEN
Last Name:SIEGFRIED
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 CEDAR DR
Mailing Address - Street 2:
Mailing Address - City:WEST MILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45383-1207
Mailing Address - Country:US
Mailing Address - Phone:937-698-5905
Mailing Address - Fax:937-236-8599
Practice Address - Street 1:7069 TAYLORSVILLE RD
Practice Address - Street 2:SUITE E
Practice Address - City:HUBER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:45424-3184
Practice Address - Country:US
Practice Address - Phone:937-236-8599
Practice Address - Fax:937-236-8599
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH014148171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor