Provider Demographics
NPI:1104570589
Name:SIEMSEN, MIRANDA NICOLE
Entity type:Individual
Prefix:MISS
First Name:MIRANDA
Middle Name:NICOLE
Last Name:SIEMSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 E JOE ORR RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60411-1225
Mailing Address - Country:US
Mailing Address - Phone:708-733-9229
Mailing Address - Fax:
Practice Address - Street 1:5117 MAIN ST
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-4654
Practice Address - Country:US
Practice Address - Phone:708-228-4076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-04
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-22-201593106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician