Provider Demographics
NPI:1124149513
Name:SIEGEL, JON HOWARD (PHD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:HOWARD
Last Name:SIEGEL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 STATE ST
Mailing Address - Street 2:SUITE 413
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-5112
Mailing Address - Country:US
Mailing Address - Phone:207-942-2627
Mailing Address - Fax:207-942-2627
Practice Address - Street 1:6 STATE ST
Practice Address - Street 2:SUITE 413
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5112
Practice Address - Country:US
Practice Address - Phone:207-942-2627
Practice Address - Fax:207-942-2627
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TA0400X, 103TC2200X, 103TF0000X, 103TF0200X, 103TP2701X
MEPS744103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
Not Answered103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Not Answered103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MESI-MM3917Medicare ID - Type Unspecified