Healthcare Provider Details

I. General information

NPI: 1366059024
Provider Name (Legal Business Name): SHEREE NIBLACK SPECIALIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHEREE NIBLACK

II. Dates (important events)

Enumeration Date: 09/28/2020
Last Update Date: 06/16/2023
Certification Date: 06/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1939 DIVISION AVE. S
GRAND RAPIDS MI
49507-2480
US

IV. Provider business mailing address

1939 DIVISION AVE. S
GRAND RAPIDS MI
49507-2480
US

V. Phone/Fax

Practice location:
  • Phone: 616-247-3815
  • Fax: 616-245-0450
Mailing address:
  • Phone: 616-247-3815
  • Fax: 616-245-0450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: