MEDICARE: MS. KATHRYN MARIE SIEGENTHALER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	6801071902	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6801071902	OTHER	MI	CLINICAL SOCIAL WORKER

General Provider Information

NPI Number	:	1942327440
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KATHRYN MARIE SIEGENTHALER

Provider Business Mailing Address
First Line	:	621 COLLEGE AVE SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49503-5305
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1101 BALL AVE NE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49505-5904
Country	:	US
Telephone Number	:	616-452-9072
Fax Number	:	616-456-5800

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2007
Last Update Date	:	07/08/2007

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