Provider Demographics
NPI:1104193077
Name:HERBERT, CODY MASON (MS, ATC)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:MASON
Last Name:HERBERT
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 W MARSHALL ST
Mailing Address - Street 2:APT 2
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-3546
Mailing Address - Country:US
Mailing Address - Phone:973-903-7663
Mailing Address - Fax:
Practice Address - Street 1:512 CAMPUS RD.
Practice Address - Street 2:TEAGLE HALL
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850
Practice Address - Country:US
Practice Address - Phone:607-255-4237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-21
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002075-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer