Provider Demographics
NPI:1396074837
Name:SIEGEL, MATTHEW PHILIP (PHD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:PHILIP
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 1:26 COURT ST
Mailing Address - Street 2:SUITE 1618
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11242-1116
Mailing Address - Country:US
Mailing Address - Phone:917-439-3141
Mailing Address - Fax:
Practice Address - Street 1:26 COURT ST
Practice Address - Street 2:SUITE 1618
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11242-1116
Practice Address - Country:US
Practice Address - Phone:917-439-3141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-11
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019172103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA300055086OtherMEDICARE PTAN