Provider Demographics
NPI:1053499749
Name:BOBERG, MICHELE JANINE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:JANINE
Last Name:BOBERG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 N BITTERSWEET LN
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-3754
Mailing Address - Country:US
Mailing Address - Phone:765-286-8788
Mailing Address - Fax:765-288-4044
Practice Address - Street 1:4607 N WHEELING AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-1220
Practice Address - Country:US
Practice Address - Phone:765-288-1110
Practice Address - Fax:765-288-4044
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041822A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN500867OtherVALUE OPTIONS
IN000000316087OtherANTHEM BCBS
IN200451310Medicaid
IN708119000OtherMAGELLAN
IN708119000OtherMAGELLAN