=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609277227
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMILY SIEGEL, LCSW PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2014
-----------------------------------------------------
Last Update Date | 09/15/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 507 S 4TH ST
-----------------------------------------------------
City | LARAMIE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82070-3753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-399-4508
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 507 S 4TH ST
-----------------------------------------------------
City | LARAMIE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82070-3753
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-399-4508
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | GILLIAN C SIEGEL
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 307-399-4508
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | WY 717
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------