Basic Information
| Provider Information | |||||||||
| NPI: | 1184655490 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIEMER | ||||||||
| FirstName: | MARGARET | ||||||||
| MiddleName: | GRACE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OTR/L; CLT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHANNON JENNINGS | ||||||||
| OtherFirstName: | MARGARET | ||||||||
| OtherMiddleName: | GRACE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | OTR/L; CLT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10505 19TH AVE SE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982084280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4085700510 | ||||||||
| FaxNumber: | 4085704018 | ||||||||
| Practice Location | |||||||||
| Address1: | 9514 4TH ST NE | ||||||||
| Address2: | 101 | ||||||||
| City: | LAKE STEVENS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982581937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253972327 | ||||||||
| FaxNumber: | 4253770283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 04/21/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XH1200X | OT 6976 | CA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand | 225XH1200X | OT00004496 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Hand |
ID Information
| ID | Type | State | Issuer | Description | OT00004496 | 01 | WA | WA LICENSE | OTHER | OT0069760 | 01 | CA | BLUE SHIELD | OTHER |