Provider Demographics
NPI:1952410060
Name:HOMAN, MIKE P (LCSW)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:P
Last Name:HOMAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:PHILLIP
Other - Last Name:HOMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:1 SAINT ANTHONY'S WAY
Mailing Address - Street 2:815 E 5TH ST. SUIT 101
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002
Mailing Address - Country:US
Mailing Address - Phone:618-465-2571
Mailing Address - Fax:618-463-5147
Practice Address - Street 1:815 E 5TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002
Practice Address - Country:US
Practice Address - Phone:618-474-6246
Practice Address - Fax:618-474-6242
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0044071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149.004407OtherILLINOIS LCSW LICENSE