Provider Demographics
NPI:1144784141
Name:SIEBOTT, CORINNE ELIZABETH (BCBA)
Entity type:Individual
Prefix:
First Name:CORINNE
Middle Name:ELIZABETH
Last Name:SIEBOTT
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:CORINNE
Other - Middle Name:ELIZABETH
Other - Last Name:SEVENISH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:4634 N TRIPLE CROWN DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-8507
Mailing Address - Country:US
Mailing Address - Phone:317-750-7479
Mailing Address - Fax:
Practice Address - Street 1:1180 S LIBERTY DR STE 410
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-5178
Practice Address - Country:US
Practice Address - Phone:812-650-4432
Practice Address - Fax:812-650-4432
Is Sole Proprietor?:No
Enumeration Date:2019-01-24
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-18-33545103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst