MEDICARE: MARILYN SIEGEL LCSW

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	1041C0700X	Clinical Social Worker	149-005494	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	149-005494	OTHER	IL	LCSW

General Provider Information

NPI Number	:	1548399041
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARILYN SIEGEL LCSW

Provider Business Mailing Address
First Line	:	3145 W PRATT BLVD
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60645-4125
Country	:	US
Telephone Number	:	773-866-5035
Fax Number	:

Provider Business Practice Location Address
First Line	:	3525 W PETERSON AVE STE 400
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-3324
Country	:	US
Telephone Number	:	773-866-5035
Fax Number	:

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

Provider Enumeration Date	:	03/02/2007
Last Update Date	:	01/24/2020

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