Provider Demographics
NPI:1619396736
Name:KNOBELOCH, MICHAEL (PSYD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:KNOBELOCH
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 604
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61702-0604
Mailing Address - Country:US
Mailing Address - Phone:309-706-3190
Mailing Address - Fax:309-588-4115
Practice Address - Street 1:102 W KENWOOD AVE
Practice Address - Street 2:SUITE 120A
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4368
Practice Address - Country:US
Practice Address - Phone:309-706-3190
Practice Address - Fax:309-588-4115
Is Sole Proprietor?:No
Enumeration Date:2014-04-16
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
IL071009106103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional