Healthcare Provider Details

I. General information

NPI: 1699708636
Provider Name (Legal Business Name): THERESE MARIE LUCIETTO-SIERADZKI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 06/24/2020
Certification Date: 06/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 CADILLAC CT STE 7
BELVIDERE IL
61008-1733
US

IV. Provider business mailing address

PO BOX 298
BELVIDERE IL
61008-0298
US

V. Phone/Fax

Practice location:
  • Phone: 815-544-0087
  • Fax: 815-544-0088
Mailing address:
  • Phone: 815-544-0087
  • Fax: 815-544-0088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number036102862
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036102862
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: