Provider Demographics
NPI:1417483785
Name:AUBERRY, SEQOUYA CHIASSA
Entity Type:Individual
Prefix:
First Name:SEQOUYA
Middle Name:CHIASSA
Last Name:AUBERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 SCIENCE PKWY
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-2560
Mailing Address - Country:US
Mailing Address - Phone:517-927-8696
Mailing Address - Fax:
Practice Address - Street 1:2770 CARPENTER RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108
Practice Address - Country:US
Practice Address - Phone:734-585-5053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-05
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIT3X985693106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician