Provider Demographics
NPI:1205258084
Name:SIEKLUCKI, KIMBERLY
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:
Last Name:SIEKLUCKI
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 1:5148 LOVERS LN
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-1572
Mailing Address - Country:US
Mailing Address - Phone:269-343-3010
Mailing Address - Fax:269-343-3017
Practice Address - Street 1:5148 LOVERS LN
Practice Address - Street 2:SUITE 2
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-1572
Practice Address - Country:US
Practice Address - Phone:269-343-3010
Practice Address - Fax:269-343-3017
Is Sole Proprietor?:No
Enumeration Date:2014-01-13
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015819103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling