Provider Demographics
NPI:1093828170
Name:HERRERA, LOURDES M (MSPT)
Entity Type:Individual
Prefix:MS
First Name:LOURDES
Middle Name:M
Last Name:HERRERA
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 SE 164TH AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9644
Mailing Address - Country:US
Mailing Address - Phone:360-256-4425
Mailing Address - Fax:360-254-1844
Practice Address - Street 1:14411 NE 20TH AVE STE 101
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-6432
Practice Address - Country:US
Practice Address - Phone:360-574-9293
Practice Address - Fax:360-574-9283
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT000068742251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8436891Medicaid
WA8941150OtherWA DEPT OF L&I CRIME VICT
WA0205240OtherWA DEPT OF LABOR & INDUST
WA8854823Medicare ID - Type Unspecified