Provider Demographics
NPI:1073957296
Name:HERMANN, RANDY (MA,LPC)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:HERMANN
Suffix:
Gender:M
Credentials:MA,LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24600 COTTAGE LN
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48089-4710
Mailing Address - Country:US
Mailing Address - Phone:586-491-0281
Mailing Address - Fax:
Practice Address - Street 1:26862 WOODWARD AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-0957
Practice Address - Country:US
Practice Address - Phone:248-398-0740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-18
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401010673101Y00000X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional