Provider Demographics
NPI:1811946395
Name:SIEGEL, WAYNE GREGG (PHD)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:GREGG
Last Name:SIEGEL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2741 INGLEWOOD AVE S
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-3929
Mailing Address - Country:US
Mailing Address - Phone:952-929-4869
Mailing Address - Fax:612-605-0108
Practice Address - Street 1:VA MEDICAL CENTER (116B)
Practice Address - Street 2:ONE VETERANS DRIVE
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417
Practice Address - Country:US
Practice Address - Phone:612-467-4024
Practice Address - Fax:612-727-5964
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MNLP3393103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical