Healthcare Provider Details

I. General information

NPI: 1174005094
Provider Name (Legal Business Name): GEMMA SIEBERT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2018
Last Update Date: 09/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 S MAIN ST
BERRYVILLE AR
72616-4330
US

IV. Provider business mailing address

208 N SPRINGFIELD AVE APT 2
GREEN FOREST AR
72638-2459
US

V. Phone/Fax

Practice location:
  • Phone: 870-423-1077
  • Fax:
Mailing address:
  • Phone: 708-305-6754
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: