Provider Demographics
NPI:1265608087
Name:KENNETH A SIEGEL, PH.D., PC
Entity type:Organization
Organization Name:KENNETH A SIEGEL, PH.D., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:SIEGEL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:757-422-9733
Mailing Address - Street 1:933 FIRST COLONIAL RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-3172
Mailing Address - Country:US
Mailing Address - Phone:757-422-9733
Mailing Address - Fax:757-422-4078
Practice Address - Street 1:933 FIRST COLONIAL RD
Practice Address - Street 2:SUITE 201
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-3172
Practice Address - Country:US
Practice Address - Phone:757-422-9733
Practice Address - Fax:757-422-4078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810000887103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA620000012OtherMEDICARE
VA083028OtherSENTARA
VA006215OtherANTHEM BLUE CROSS/BLUE SHIELD
VA7714203Medicaid
VA4107739OtherAETNA