Provider Demographics
NPI:1881172070
Name:SIEGEL, MADISEN AVERY
Entity type:Individual
Prefix:
First Name:MADISEN
Middle Name:AVERY
Last Name:SIEGEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1081 WESTWOOD BLVD STE 234
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-2931
Mailing Address - Country:US
Mailing Address - Phone:310-713-2890
Mailing Address - Fax:
Practice Address - Street 1:1081 WESTWOOD BLVD STE 234
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-2931
Practice Address - Country:US
Practice Address - Phone:310-713-2890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT95510106H00000X
CAMFT114566106H00000X
CA114566106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist