Healthcare Provider Details

I. General information

NPI: 1154327211
Provider Name (Legal Business Name): CAROL F. SIEGEL PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1516 W LAKE ST STE 214
MINNEAPOLIS MN
55408-2554
US

IV. Provider business mailing address

1516 W LAKE ST STE 214
MINNEAPOLIS MN
55408-2554
US

V. Phone/Fax

Practice location:
  • Phone: 612-825-4307
  • Fax: 612-821-4349
Mailing address:
  • Phone: 612-825-4307
  • Fax: 612-821-4349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP4422
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: