Healthcare Provider Details

I. General information

NPI: 1376028910
Provider Name (Legal Business Name): TINA GRAY-SIEBERS LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2018
Last Update Date: 03/29/2024
Certification Date: 03/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W4711 CASTLE DR
SHERWOOD WI
54169-9681
US

IV. Provider business mailing address

W4711 CASTLE DR
SHERWOOD WI
54169-9681
US

V. Phone/Fax

Practice location:
  • Phone: 920-287-0406
  • Fax: 920-287-0410
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7053-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: