Provider Demographics
NPI:1003895202
Name:HEROD, EYVONNE (PTA)
Entity Type:Individual
Prefix:
First Name:EYVONNE
Middle Name:
Last Name:HEROD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 PLEASANT LN
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75964-6014
Mailing Address - Country:US
Mailing Address - Phone:936-560-0453
Mailing Address - Fax:936-559-8767
Practice Address - Street 1:4632 NE STALLINGS DR
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-1608
Practice Address - Country:US
Practice Address - Phone:936-560-1816
Practice Address - Fax:936-560-3554
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2013660225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant