Provider Demographics
NPI:1821322470
Name:SEIBOLD, ANDREA (AUD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:SEIBOLD
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:PETERSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 716
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76244-0716
Mailing Address - Country:US
Mailing Address - Phone:817-605-7544
Mailing Address - Fax:
Practice Address - Street 1:5449 LAKE POWELL DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-4341
Practice Address - Country:US
Practice Address - Phone:817-605-7544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-30
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80069231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist