Provider Demographics
NPI:1003178807
Name:HERBERT, MARK SCOTT
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:SCOTT
Last Name:HERBERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N4231 STATE HIGHWAY 22
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-6130
Mailing Address - Country:US
Mailing Address - Phone:715-526-3158
Mailing Address - Fax:715-526-6225
Practice Address - Street 1:N4231 STATE HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-6130
Practice Address - Country:US
Practice Address - Phone:715-526-3158
Practice Address - Fax:715-526-6225
Is Sole Proprietor?:No
Enumeration Date:2012-06-08
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2986225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist