Provider Demographics
NPI:1740582006
Name:SIEGEL, ILYSSA (PSYD)
Entity type:Individual
Prefix:DR
First Name:ILYSSA
Middle Name:
Last Name:SIEGEL
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3506 AQUILA AVE N
Mailing Address - Street 2:
Mailing Address - City:NEW HOPE
Mailing Address - State:MN
Mailing Address - Zip Code:55427-1845
Mailing Address - Country:US
Mailing Address - Phone:763-746-6144
Mailing Address - Fax:
Practice Address - Street 1:3506 AQUILA AVE N
Practice Address - Street 2:
Practice Address - City:NEW HOPE
Practice Address - State:MN
Practice Address - Zip Code:55427-1845
Practice Address - Country:US
Practice Address - Phone:763-746-6144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-18
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6139103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical