Provider Demographics
NPI:1003293572
Name:HERNBERG, DONALD
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:
Last Name:HERNBERG
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 1:356 WINDHAM RD
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-3530
Mailing Address - Country:US
Mailing Address - Phone:860-301-4468
Mailing Address - Fax:860-456-8968
Practice Address - Street 1:356 WINDHAM RD
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-3530
Practice Address - Country:US
Practice Address - Phone:860-301-4468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-04
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT082772436103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst