=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275357238
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANN MARIE SIEKKINEN LICSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2024
-----------------------------------------------------
Last Update Date | 11/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11660 ROUND LAKE BLVD NW
-----------------------------------------------------
City | COON RAPIDS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55433-2638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-317-0718
-----------------------------------------------------
Fax | 763-767-0912
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11703 BRUNSWICK AVE N
-----------------------------------------------------
City | CHAMPLIN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55316-2485
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-464-1741
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 31291
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------