MEDICARE: DUSTIN SIEGEL PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	071009259	IL

General Provider Information

NPI Number	:	1093342156
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DUSTIN SIEGEL PSYD

Provider Business Mailing Address
First Line	:	1820 W WEBSTER AVE STE 400
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-4892
Country	:	US
Telephone Number	:	312-248-3048
Fax Number	:

Provider Business Practice Location Address
First Line	:	1820 W WEBSTER AVE STE 400
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-4892
Country	:	US
Telephone Number	:	312-248-3048
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/26/2020
Last Update Date	:	03/25/2021

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