Provider Demographics
NPI:1164428751
Name:HERZOG, DEBORAH J (OTR/L)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:J
Last Name:HERZOG
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3811 W 52ND ST
Mailing Address - Street 2:
Mailing Address - City:ROELAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66205-1458
Mailing Address - Country:US
Mailing Address - Phone:913-579-8556
Mailing Address - Fax:
Practice Address - Street 1:3811 W 52ND ST
Practice Address - Street 2:
Practice Address - City:ROELAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66205-1458
Practice Address - Country:US
Practice Address - Phone:913-579-8556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-28
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004028607225X00000X, 225XP0200X
KS17-00917225XP0200X, 225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201858547OtherGREAT-WEST HC PROVIDER #
MO34948018OtherBCBS KANSAS CITY #
Q33540Medicare UPIN
MO201858547OtherGREAT-WEST HC PROVIDER #