Basic Information
| Provider Information | |||||||||
| NPI: | 1720257207 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SIEGL | ||||||||
| FirstName: | WALTER | ||||||||
| MiddleName: | OTTO | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1560 E MAPLE RD | ||||||||
| Address2: | STE 400-CREDENTIALING | ||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480831138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135778693 | ||||||||
| FaxNumber: | 3139933974 | ||||||||
| Practice Location | |||||||||
| Address1: | 3901 CHRYSLER SERVICE DR | ||||||||
| Address2: | TOLAN PARK | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139933964 | ||||||||
| FaxNumber: | 3139931372 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2008 | ||||||||
| LastUpdateDate: | 09/23/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801089786 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.