Provider Demographics
NPI:1316532799
Name:SIEGEL, ERIC RANDI (LCSW)
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:RANDI
Last Name:SIEGEL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:MR
Other - First Name:ERIC
Other - Middle Name:RANDI
Other - Last Name:SIEGEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:211 9TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-1705
Mailing Address - Country:US
Mailing Address - Phone:321-662-6055
Mailing Address - Fax:
Practice Address - Street 1:211 9TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-1705
Practice Address - Country:US
Practice Address - Phone:321-662-6055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-07
Last Update Date:2021-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW49311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSW4931OtherSTATE LICENSE