Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | ||
N | 103G00000X | Clinical Psychologist | PS744 | ME |
N | 103TC0700X | Clinical Psychologist | PS744 | ME |
N | 103TC2200X | Clinical Child & Adolescent Psychologist | ||
N | 103TF0000X | Family Psychologist | ||
N | 103TF0200X | Forensic Psychologist | ||
N | 103TP2701X | Group Psychotherapist |
NPI | 1124149513 |
---|---|
Provider Name | Jon Howard Siegel |
First Address | Bangor, ME 04401-5112 |
Second Address | Bangor, ME 04401-5112 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/04/2007 |
Last Update Date | 08/07/2007 |