Provider Demographics
NPI:1629620091
Name:FIEBELKORN, SANDRA MICHELLE
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:MICHELLE
Last Name:FIEBELKORN
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 1:406 HANNAH ST
Mailing Address - Street 2:
Mailing Address - City:ROSCOMMON
Mailing Address - State:MI
Mailing Address - Zip Code:48653-8311
Mailing Address - Country:US
Mailing Address - Phone:989-273-9023
Mailing Address - Fax:
Practice Address - Street 1:406 HANNAH ST
Practice Address - Street 2:
Practice Address - City:ROSCOMMON
Practice Address - State:MI
Practice Address - Zip Code:48653-8311
Practice Address - Country:US
Practice Address - Phone:989-273-9023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician