Basic Information
Provider Information | |||||||||
NPI: | 1487862165 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SIBERSKI | ||||||||
FirstName: | JODI | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GAWER | ||||||||
OtherFirstName: | JODI | ||||||||
OtherMiddleName: | LYNN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 114 ORCHARD LAKE RD | ||||||||
Address2: |   | ||||||||
City: | PONTIAC | ||||||||
State: | MI | ||||||||
PostalCode: | 483412244 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2488587766 | ||||||||
FaxNumber: | 2488587201 | ||||||||
Practice Location | |||||||||
Address1: | 2045 E WEST MAPLE RD | ||||||||
Address2: | SUITE D-407 | ||||||||
City: | COMMERCE TOWNSHIP | ||||||||
State: | MI | ||||||||
PostalCode: | 483903801 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2486243811 | ||||||||
FaxNumber: | 2486240368 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/18/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | 1883825 | 05 | MI |   | MEDICAID |