Provider Demographics
NPI:1669664165
Name:SEIBERT, NICOLE MARIE
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:MARIE
Last Name:SEIBERT
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 1:2500 MANN RD LOT 334
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-4290
Mailing Address - Country:US
Mailing Address - Phone:248-245-2002
Mailing Address - Fax:
Practice Address - Street 1:2500 MANN RD LOT 334
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-4290
Practice Address - Country:US
Practice Address - Phone:248-245-2002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-17
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201007083174400000X
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist