Provider Demographics
NPI:1194215558
Name:RAYMOND HERZOG MA LLP
Entity Type:Organization
Organization Name:RAYMOND HERZOG MA LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:HERZOG
Authorized Official - Suffix:
Authorized Official - Credentials:LLP
Authorized Official - Phone:616-901-2784
Mailing Address - Street 1:4829 E BELTLINE AVE NE STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9349
Mailing Address - Country:US
Mailing Address - Phone:616-364-3301
Mailing Address - Fax:
Practice Address - Street 1:4829 E BELTLINE AVE NE STE 100
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9349
Practice Address - Country:US
Practice Address - Phone:616-364-3301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-11
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011394103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty