Healthcare Provider Details

I. General information

NPI: 1215292982
Provider Name (Legal Business Name): MS. VANESSA M SIEVERT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2012
Last Update Date: 01/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2043 STEPHANIE CT
BLACK EARTH WI
53515-9520
US

IV. Provider business mailing address

2043 STEPHANIE CT
BLACK EARTH WI
53515-9520
US

V. Phone/Fax

Practice location:
  • Phone: 608-298-8087
  • Fax:
Mailing address:
  • Phone: 608-298-8087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5209-026
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: