Provider Demographics
NPI:1104209493
Name:BETH SIPPLE JANICK LLC
Entity Type:Organization
Organization Name:BETH SIPPLE JANICK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:BETH
Authorized Official - Middle Name:SIPPLE
Authorized Official - Last Name:JANICK
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:517-410-0729
Mailing Address - Street 1:4572 S HAGADORN RD
Mailing Address - Street 2:SUITE 3B
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-5385
Mailing Address - Country:US
Mailing Address - Phone:517-410-0729
Mailing Address - Fax:517-999-3675
Practice Address - Street 1:4572 S HAGADORN RD
Practice Address - Street 2:SUITE 3B
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5385
Practice Address - Country:US
Practice Address - Phone:517-410-0729
Practice Address - Fax:517-999-3675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-03
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704194601101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOM59570Medicare PIN