Provider Demographics
NPI:1205224755
Name:HERZOG, VIRGINIA
Entity Type:Individual
Prefix:
First Name:VIRGINIA
Middle Name:
Last Name:HERZOG
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 1:1011 BROOKSIDE RD # 122F
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18106-9020
Mailing Address - Country:US
Mailing Address - Phone:484-891-1258
Mailing Address - Fax:
Practice Address - Street 1:2132 S 12TH ST
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-4810
Practice Address - Country:US
Practice Address - Phone:484-350-3001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-07
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC007967101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health