Healthcare Provider Details

I. General information

NPI: 1053499749
Provider Name (Legal Business Name): MICHELE JANINE BOBERG PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4607 N WHEELING AVE
MUNCIE IN
47304-1220
US

IV. Provider business mailing address

715 N BITTERSWEET LN
MUNCIE IN
47304-3754
US

V. Phone/Fax

Practice location:
  • Phone: 765-288-1110
  • Fax: 765-288-4044
Mailing address:
  • Phone: 765-286-8788
  • Fax: 765-288-4044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20041822A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: