Provider Demographics
NPI:1073047262
Name:HERRON, MICHELLE (LMT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:HERRON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5252 BALBOA AVE STE 701
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-6930
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5252 BALBOA AVE STE 701
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-6930
Practice Address - Country:US
Practice Address - Phone:858-337-7801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-14
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2545225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist