Provider Demographics
NPI:1386617207
Name:SIEVEKA, CORA BETHANE JACKSON (LGSW)
Entity type:Individual
Prefix:
First Name:CORA BETHANE
Middle Name:JACKSON
Last Name:SIEVEKA
Suffix:
Gender:F
Credentials:LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 826
Mailing Address - Street 2:TRICO CORPORATION
Mailing Address - City:LEXINGTON PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20653-0826
Mailing Address - Country:US
Mailing Address - Phone:301-862-4966
Mailing Address - Fax:301-862-5554
Practice Address - Street 1:21770 FDR BOULEVARD
Practice Address - Street 2:
Practice Address - City:LEXINGTON PARK
Practice Address - State:MD
Practice Address - Zip Code:20653
Practice Address - Country:US
Practice Address - Phone:301-862-4966
Practice Address - Fax:301-862-5554
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDG11552101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
407LMedicare ID - Type Unspecified
G01516Medicare ID - Type Unspecified