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NPI Code Detail

MEDICARE: SHEREE NIBLACK SPECIALIST

MEDICARE: SHEREE NIBLACK SPECIALIST
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YA0400XAddiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number : 1366059024
Entity Type Code : Individual
Provider Name (Legal Business Name) : SHEREE NIBLACK SPECIALIST
Provider Business Mailing Address
First Line : 1939 DIVISION AVE. S
Second Line :
City : GRAND RAPIDS
State : MI
Zip : 49507-2480
Country : US
Telephone Number : 616-247-3815
Fax Number : 616-245-0450
Provider Business Practice Location Address
First Line : 1939 DIVISION AVE. S
Second Line :
City : GRAND RAPIDS
State : MI
Zip : 49507-2480
Country : US
Telephone Number : 616-247-3815
Fax Number : 616-245-0450
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/28/2020
Last Update Date : 06/16/2023

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