Provider Demographics
NPI:1114535655
Name:HERRIN, MATT
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:HERRIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 S INDUSTRIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30701-3075
Mailing Address - Country:US
Mailing Address - Phone:706-624-3000
Mailing Address - Fax:706-624-3001
Practice Address - Street 1:212 W 3RD ST SW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-2802
Practice Address - Country:US
Practice Address - Phone:706-295-4242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT007798225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist