Provider Demographics
NPI:1366596611
Name:HANDWERK, MICHAEL (PHD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:HANDWERK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 US HIGHWAY 45 N
Mailing Address - Street 2:
Mailing Address - City:ELDORADO
Mailing Address - State:IL
Mailing Address - Zip Code:62930-3767
Mailing Address - Country:US
Mailing Address - Phone:618-273-7723
Mailing Address - Fax:618-273-3384
Practice Address - Street 1:1007 US HIGHWAY 45 N
Practice Address - Street 2:
Practice Address - City:ELDORADO
Practice Address - State:IL
Practice Address - Zip Code:62930-3767
Practice Address - Country:US
Practice Address - Phone:618-273-7723
Practice Address - Fax:618-273-3384
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE490103T00000X
IL007389103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47037660631Medicaid