Provider Demographics
NPI:1376277251
Name:HEIRONIMUS, MICHELLE (MHC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:HEIRONIMUS
Suffix:
Gender:F
Credentials:MHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12948 COLDWATER RD STE 101
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-8016
Mailing Address - Country:US
Mailing Address - Phone:260-373-0880
Mailing Address - Fax:260-373-0881
Practice Address - Street 1:12948 COLDWATER RD STE 101
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-8016
Practice Address - Country:US
Practice Address - Phone:260-373-0880
Practice Address - Fax:260-373-0881
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-15
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health