Provider Demographics
NPI:1083859557
Name:MARK A. HERRMANN, PH.D., P.C.
Entity Type:Organization
Organization Name:MARK A. HERRMANN, PH.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:HERRMANN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:812-331-0946
Mailing Address - Street 1:3705 N BITTERSWEET DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47408-9656
Mailing Address - Country:US
Mailing Address - Phone:812-331-0946
Mailing Address - Fax:
Practice Address - Street 1:3705 N BITTERSWEET DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-9656
Practice Address - Country:US
Practice Address - Phone:812-331-0946
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-11
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN57000132A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200043730BMedicaid