Healthcare Provider Details

I. General information

NPI: 1033545611
Provider Name (Legal Business Name): DODY STAR SIEGFRIED MAPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DODY STAR FREED MDIV

II. Dates (important events)

Enumeration Date: 09/16/2013
Last Update Date: 09/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 MARKET ST
BANGOR PA
18013-1901
US

IV. Provider business mailing address

2650 NORTHWOOD AVE.
EASTON PENNSYLVANIA
18045
UM

V. Phone/Fax

Practice location:
  • Phone: 610-588-9109
  • Fax:
Mailing address:
  • Phone: 610-250-0752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: