Provider Demographics
NPI:1043358682
Name:HABERMAN, MICHELE EVONNE (LAC)
Entity type:Individual
Prefix:MS
First Name:MICHELE
Middle Name:EVONNE
Last Name:HABERMAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:966 GAMBRILLS LN
Mailing Address - Street 2:
Mailing Address - City:GAMBRILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21054-1017
Mailing Address - Country:US
Mailing Address - Phone:410-674-4674
Mailing Address - Fax:
Practice Address - Street 1:2124 PRIEST BRIDGE DR
Practice Address - Street 2:SUITE #10
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-2936
Practice Address - Country:US
Practice Address - Phone:410-721-3789
Practice Address - Fax:410-721-3036
Is Sole Proprietor?:No
Enumeration Date:2007-02-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU00715171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDBL55MEOtherBLUE CROSS BLUE SHIELD