Provider Demographics
NPI:1053314344
Name:HERZ, GORDON I (PHD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:I
Last Name:HERZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:478 COMMERCE DR
Mailing Address - Street 2:STE 204
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-4993
Mailing Address - Country:US
Mailing Address - Phone:608-833-7533
Mailing Address - Fax:
Practice Address - Street 1:478 COMMERCE DR
Practice Address - Street 2:STE 204
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-4993
Practice Address - Country:US
Practice Address - Phone:608-833-7533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-31
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1715103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI134252791OtherFEDERAL EIN
WI134252791OtherFEDERAL EIN