Provider Demographics
NPI:1245695691
Name:SIEGEL, ELIZABETH
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:SIEGEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:SIEGEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:1861 EATON RD
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-1726
Mailing Address - Country:US
Mailing Address - Phone:248-930-9686
Mailing Address - Fax:
Practice Address - Street 1:1861 EATON RD
Practice Address - Street 2:
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-1726
Practice Address - Country:US
Practice Address - Phone:248-930-9686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-29
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010639981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical