Provider Demographics
NPI:1649269937
Name:SIEGEL, KENNETH A (PHD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:SIEGEL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:933 FIRST COLONIAL RD
Mailing Address - Street 2:#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:#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
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA081000087103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7714203Medicaid
VA7714203Medicaid