Healthcare Provider Details

I. General information

NPI: 1932412913
Provider Name (Legal Business Name): GENIE SIEBER ULLRICH PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2010
Last Update Date: 07/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 REELFOOT ST
TIPTONVILLE TN
38079-1607
US

IV. Provider business mailing address

1034 REELFOOT ST
TIPTONVILLE TN
38079-1607
US

V. Phone/Fax

Practice location:
  • Phone: 731-253-6681
  • Fax: 731-253-8014
Mailing address:
  • Phone: 731-253-7266
  • Fax: 731-253-7267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2791
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: