Provider Demographics
NPI:1154661213
Name:HERARD, ANNE MARIE
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:MARIE
Last Name:HERARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2309 W CLINTON ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33604-5208
Mailing Address - Country:US
Mailing Address - Phone:813-770-8739
Mailing Address - Fax:
Practice Address - Street 1:2309 W CLINTON ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33604-5208
Practice Address - Country:US
Practice Address - Phone:813-770-8739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-26
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL691283496320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL691283496Medicaid