=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699708636
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THERESE MARIE LUCIETTO-SIERADZKI M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2006
-----------------------------------------------------
Last Update Date | 06/24/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 205 CADILLAC CT STE 7
-----------------------------------------------------
City | BELVIDERE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61008-1733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-544-0087
-----------------------------------------------------
Fax | 815-544-0088
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 298
-----------------------------------------------------
City | BELVIDERE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61008-0298
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-544-0087
-----------------------------------------------------
Fax | 815-544-0088
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QA0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 036102862
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 036102862
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------