Provider Demographics
NPI:1871864579
Name:HOBERMAN CLINIC
Entity Type:Organization
Organization Name:HOBERMAN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MELVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOBERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LLP, LCSW, CAAC
Authorized Official - Phone:313-277-1166
Mailing Address - Street 1:1800 GRINDLEY PARK ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2553
Mailing Address - Country:US
Mailing Address - Phone:313-277-1166
Mailing Address - Fax:313-277-3414
Practice Address - Street 1:1800 GRINDLEY PARK ST
Practice Address - Street 2:SUITE 3
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2553
Practice Address - Country:US
Practice Address - Phone:313-277-1166
Practice Address - Fax:313-277-3414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-26
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301002903101YP2500X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI195511OtherVALUE OPTIONS
MI0007263796OtherAETNA
MI0897467OtherBCBS/BCN
MI195511OtherVALUE OPTIONS