Provider Demographics
NPI:1043758261
Name:HERTZOG, ASHLEY E (MA)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:E
Last Name:HERTZOG
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7302 N DIXON AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33604-4812
Mailing Address - Country:US
Mailing Address - Phone:720-300-9195
Mailing Address - Fax:
Practice Address - Street 1:4144 N ARMENIA AVE STE 355
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6450
Practice Address - Country:US
Practice Address - Phone:813-519-5945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-08
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO15095101YM0800X
FLIMH16923101YM0800X
CO17731101YM0800X
FL18016101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health