Provider Demographics
NPI:1548831522
Name:SIEG, MARK MATTHEW I (CAP, LCSW)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:MATTHEW
Last Name:SIEG
Suffix:I
Gender:M
Credentials:CAP, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5826 27TH AVE S
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33707-5221
Mailing Address - Country:US
Mailing Address - Phone:727-301-0016
Mailing Address - Fax:
Practice Address - Street 1:5826 27TH AVE S
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:FL
Practice Address - Zip Code:33707-5221
Practice Address - Country:US
Practice Address - Phone:727-301-0016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2544101YA0400X
FLSW162091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)