Healthcare Provider Details

I. General information

NPI: 1417462730
Provider Name (Legal Business Name): MICHELE K OMARA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2680 E MAIN ST STE 121
PLAINFIELD IN
46168-2827
US

IV. Provider business mailing address

2680 E MAIN ST STE 121
PLAINFIELD IN
46168-2827
US

V. Phone/Fax

Practice location:
  • Phone: 317-517-0065
  • Fax:
Mailing address:
  • Phone: 317-517-0065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34003162A
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier34003162A
Identifier TypeOTHER
Identifier StateIN
Identifier IssuerCLINICAL SOCIAL WORKER

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: