Healthcare Provider Details

I. General information

NPI: 1609161215
Provider Name (Legal Business Name): ELISE NIEBEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ELISE KLINGAMAN

II. Dates (important events)

Enumeration Date: 06/10/2011
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5933 STONEY CREEK DR
FORT WAYNE IN
46825-4401
US

IV. Provider business mailing address

11805 WESTWIND DR
FORT WAYNE IN
46845-1337
US

V. Phone/Fax

Practice location:
  • Phone: 260-222-8510
  • Fax:
Mailing address:
  • Phone: 260-348-2486
  • 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: