Provider Demographics
NPI:1669127056
Name:BLOEBAUM, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:BLOEBAUM
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 1:2325 E NAVAJO DR
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-1920
Mailing Address - Country:US
Mailing Address - Phone:812-887-4199
Mailing Address - Fax:
Practice Address - Street 1:2325 E NAVAJO DR
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-1920
Practice Address - Country:US
Practice Address - Phone:812-887-4199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-15
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN104100000X, 222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker