Provider Demographics
NPI:1992953681
Name:SIEBERT, LEA HALVERSON (LAC)
Entity type:Individual
Prefix:
First Name:LEA
Middle Name:HALVERSON
Last Name:SIEBERT
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:LEA
Other - Middle Name:ELLEN
Other - Last Name:HALVERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1477 W WHITE MOUNTAIN BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-6767
Mailing Address - Country:US
Mailing Address - Phone:928-821-6878
Mailing Address - Fax:
Practice Address - Street 1:1477 W WHITE MOUNTAIN BLVD STE 3
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-6767
Practice Address - Country:US
Practice Address - Phone:928-821-6878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-05
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-26655225700000X
AZ010075171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist