Healthcare Provider Details

I. General information

NPI: 1740582006
Provider Name (Legal Business Name): ILYSSA SIEGEL PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2010
Last Update Date: 05/17/2024
Certification Date: 05/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3506 AQUILA AVE N
NEW HOPE MN
55427-1845
US

IV. Provider business mailing address

3506 AQUILA AVE N
NEW HOPE MN
55427-1845
US

V. Phone/Fax

Practice location:
  • Phone: 763-746-6144
  • Fax:
Mailing address:
  • Phone: 763-746-6144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP6139
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: