Provider Demographics
NPI:1649365776
Name:SIEGEL, MARJORIE B (LICSW)
Entity type:Individual
Prefix:
First Name:MARJORIE
Middle Name:B
Last Name:SIEGEL
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 470644
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE VILLAGE
Mailing Address - State:MA
Mailing Address - Zip Code:02447-0644
Mailing Address - Country:US
Mailing Address - Phone:617-731-0932
Mailing Address - Fax:
Practice Address - Street 1:1180 BEACON ST
Practice Address - Street 2:SUITE 4B
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-3885
Practice Address - Country:US
Practice Address - Phone:617-731-0932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MASW 1030148-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP07517OtherBLUE CROSS