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General NPI Number Information
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NPI Number | 1952396012
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Entity Type | Individual
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Provider Name | THEODORE SIEDLECKI JR. PH.D.
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Gender | Male
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Dates
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Enumeration Date | 09/14/2005
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Last Update Date | 04/19/2012
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Provider Practice Location Address
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Address Line | 233 HYDRAULIC RIDGE RD STE 204
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City | CHARLOTTESVILLE
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State | VA
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Zip | 22901-8129
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Country | US
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Telephone | 434-973-2526
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Fax | 434-975-5948
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Provider Business Mailing Address
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Address Line | 233 HYDRAULIC RIDGE RD STE 204
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City | CHARLOTTESVILLE
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State | VA
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Zip | 22901-8129
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Country | US
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Telephone | 434-973-2526
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Fax | 434-975-5948
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 0810001918
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License Number State | VA
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