=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548301583
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHERI A NISELY FRAZIER MSW LCSW ACSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 N MICHIGAN ST STE 320
-----------------------------------------------------
City | SOUTH BEND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46601-1295
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-287-3223
-----------------------------------------------------
Fax | 574-287-1667
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2726 HORTON CT
-----------------------------------------------------
City | NILES
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49120-9350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-687-1731
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 34003880A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------