Provider Demographics
NPI:1164026282
Name:HERZOG, TIM SCOTT
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:SCOTT
Last Name:HERZOG
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 1:4544 3RD ST NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55421-2149
Mailing Address - Country:US
Mailing Address - Phone:651-334-8321
Mailing Address - Fax:
Practice Address - Street 1:7835 MAIN ST N STE 220
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-7072
Practice Address - Country:US
Practice Address - Phone:763-400-7475
Practice Address - Fax:763-400-7473
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty