1093828170 NPI number — MS. LOURDES M HERRERA M.S.P.T.

Table of content: (NPI 1619020310)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093828170 NPI number — MS. LOURDES M HERRERA M.S.P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERRERA
Provider First Name:
LOURDES
Provider Middle Name:
M
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
M.S.P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093828170
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/17/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1405 SE 164TH AVE STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98683-9644
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-256-4425
Provider Business Mailing Address Fax Number:
360-254-1844

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14411 NE 20TH AVE STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98686-6432
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-574-9293
Provider Business Practice Location Address Fax Number:
360-574-9283
Provider Enumeration Date:
08/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2251N0400X , with the licence number:  PT00006874 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8436891 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8941150 . This is a "WA DEPT OF L&I CRIME VICT" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0205240 . This is a "WA DEPT OF LABOR & INDUST" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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