Provider Demographics
NPI:1104930858
Name:SIEVERT, GALEN W (PCC-S, LICDC-CS)
Entity type:Individual
Prefix:MR
First Name:GALEN
Middle Name:W
Last Name:SIEVERT
Suffix:
Gender:M
Credentials:PCC-S, LICDC-CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1506 WOODBINE AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44313-7632
Mailing Address - Country:US
Mailing Address - Phone:330-622-5111
Mailing Address - Fax:
Practice Address - Street 1:3445 S MAIN ST
Practice Address - Street 2:
Practice Address - City:COVENTRY TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:44319-3028
Practice Address - Country:US
Practice Address - Phone:330-644-4095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH051036101YA0400X
OHE7470101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0164036Medicaid