Healthcare Provider Details

I. General information

NPI: 1306740469
Provider Name (Legal Business Name): DR. SAMUEL WOLF SIEGEL-WALLACE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 S BROAD ST STE 2240
PHILADELPHIA PA
19109-1029
US

IV. Provider business mailing address

123 S BROAD ST STE 2240
PHILADELPHIA PA
19109-1029
US

V. Phone/Fax

Practice location:
  • Phone: 267-209-0140
  • Fax:
Mailing address:
  • Phone: 267-209-0140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS020872
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: