Provider Demographics
NPI:1588776157
Name:HORGAN SIEGWORTH, MARY JANE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:HORGAN SIEGWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:IL
Mailing Address - Zip Code:61738-1748
Mailing Address - Country:US
Mailing Address - Phone:309-527-5636
Mailing Address - Fax:
Practice Address - Street 1:108 W MARKET ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3918
Practice Address - Country:US
Practice Address - Phone:309-827-5351
Practice Address - Fax:309-829-6808
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional