1861534133 NPI number — AMY HERZOG LCSW

Table of content: AMY HERZOG LCSW (NPI 1861534133)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861534133 NPI number — AMY HERZOG LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERZOG
Provider First Name:
AMY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCSW
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:
1861534133
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/14/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
175 BROME DR.
Provider Second Line Business Mailing Address:
7
Provider Business Mailing Address City Name:
VICTOR
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83455
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-360-1631
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
175 BROME DR.
Provider Second Line Business Practice Location Address:
#7
Provider Business Practice Location Address City Name:
VICTOR
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-360-1631
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/13/2007

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: 101Y00000X , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251C00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com