Basic Information
| Provider Information | |||||||||
| NPI: | 1952410060 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOMAN | ||||||||
| FirstName: | MIKE | ||||||||
| MiddleName: | P. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HOMAN | ||||||||
| OtherFirstName: | MICHAEL | ||||||||
| OtherMiddleName: | PHILLIP | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1 SAINT ANTHONY'S WAY | ||||||||
| Address2: | 815 E 5TH ST. SUIT 101 | ||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184652571 | ||||||||
| FaxNumber: | 6184635147 | ||||||||
| Practice Location | |||||||||
| Address1: | 815 E 5TH ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184746246 | ||||||||
| FaxNumber: | 6184746242 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 09/17/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 149.004407 | IL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 149.004407 | 01 | IL | ILLINOIS LCSW LICENSE | OTHER |