Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 102L00000X | Psychologist | 20042414A | IN |
Y | 103T00000X | Psychologist | 20042414A | IN |
N | 103G00000X | Clinical Psychologist | 20042414A | IN |
N | 103TC0700X | Clinical Psychologist | 20042414A | IN |
NPI | 1013233584 |
---|---|
Provider Name | Michele Koselke |
First Address | Avon, IN 46123-8441 |
Second Address | Bloomington, IN 47404-3953 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/04/2010 |
Last Update Date | 09/09/2020 |