=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396860789
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELLEN SEIGEL LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2007
-----------------------------------------------------
Last Update Date | 09/04/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6161 BUSCH BLVD SUITE 120
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43229-2508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-842-4374
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 80 ANTELOPE WAY APT 2B
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43235-5414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-842-4374
-----------------------------------------------------
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 | 1070008
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | R021702
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------