Provider Demographics
NPI:1730469628
Name:HOMMERT, MICHELLE MARIE (MSW, CADC, LCSW)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:MARIE
Last Name:HOMMERT
Suffix:
Gender:F
Credentials:MSW, CADC, LCSW
Other - Prefix:MISS
Other - First Name:MICHELLE
Other - Middle Name:MARIE
Other - Last Name:ROTTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1217 HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-2446
Mailing Address - Country:US
Mailing Address - Phone:618-520-2950
Mailing Address - Fax:
Practice Address - Street 1:50 NORTHGATE INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-6805
Practice Address - Country:US
Practice Address - Phone:618-877-4420
Practice Address - Fax:618-877-9250
Is Sole Proprietor?:No
Enumeration Date:2011-08-23
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0148581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical