Provider Demographics
NPI:1992871651
Name:BOETTIGER, MARILYN SIEGEL (LCSW)
Entity type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:SIEGEL
Last Name:BOETTIGER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 HAWKRIDGE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-4611
Mailing Address - Country:US
Mailing Address - Phone:949-552-8737
Mailing Address - Fax:949-654-2402
Practice Address - Street 1:13 HAWKRIDGE
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-4611
Practice Address - Country:US
Practice Address - Phone:949-552-8737
Practice Address - Fax:949-654-2402
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS81761041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACSW081760Medicaid
SW8176AMedicare ID - Type Unspecified