Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor | C2452 | OR |
NPI | 1003217076 |
---|---|
Provider Name | Mike Siegel |
First Address | Beaverton, OR 97006-7338 |
Second Address | Beaverton, OR 97005-1600 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/09/2014 |
Last Update Date | 10/09/2014 |