Provider Demographics
NPI:1417462730
Name:OMARA, MICHELE K
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:K
Last Name:OMARA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2680 E MAIN ST STE 121
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-2827
Mailing Address - Country:US
Mailing Address - Phone:317-517-0065
Mailing Address - Fax:
Practice Address - Street 1:2680 E MAIN ST STE 121
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IN
Practice Address - Zip Code:46168-2827
Practice Address - Country:US
Practice Address - Phone:317-517-0065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-08
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003162A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN34003162AOtherCLINICAL SOCIAL WORKER