Healthcare Provider Details

I. General information

NPI: 1205661428
Provider Name (Legal Business Name): MICHELLE ANNE MUCKERHEIDE ED.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2024
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 N BLUE RD
GREENFIELD IN
46140-6512
US

IV. Provider business mailing address

110 W NORTH ST
GREENFIELD IN
46140-2172
US

V. Phone/Fax

Practice location:
  • Phone: 317-462-4491
  • Fax:
Mailing address:
  • Phone: 317-498-1384
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1100298
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: