Provider Demographics
NPI:1619305547
Name:SEBOLD, MICKI ANN (LMP)
Entity Type:Individual
Prefix:MRS
First Name:MICKI
Middle Name:ANN
Last Name:SEBOLD
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1921 1ST ST
Mailing Address - Street 2:#940
Mailing Address - City:CHENEY
Mailing Address - State:WA
Mailing Address - Zip Code:99004-2000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1921 1ST ST
Practice Address - Street 2:#940
Practice Address - City:CHENEY
Practice Address - State:WA
Practice Address - Zip Code:99004-2000
Practice Address - Country:US
Practice Address - Phone:509-939-1630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-01
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIMASS.MA.60419919174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMASS.MA.60419919OtherLMP