Provider Demographics
NPI:1164847992
Name:HERZOG-DIAL, MICHELE MARIE (LMT)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:MARIE
Last Name:HERZOG-DIAL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 SE RISLEY AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97267-2954
Mailing Address - Country:US
Mailing Address - Phone:971-998-4442
Mailing Address - Fax:503-850-4651
Practice Address - Street 1:4400 SE RISLEY AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97267-2954
Practice Address - Country:US
Practice Address - Phone:971-998-4442
Practice Address - Fax:503-850-4651
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-04
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4576247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other