Provider Demographics
NPI:1376212373
Name:HERDER, JOSEPH DAVID (LP)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:DAVID
Last Name:HERDER
Suffix:
Gender:M
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 11TH AVE N
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:MN
Mailing Address - Zip Code:55371-1411
Mailing Address - Country:US
Mailing Address - Phone:218-770-6527
Mailing Address - Fax:
Practice Address - Street 1:114 11TH AVE N
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:MN
Practice Address - Zip Code:55371-1411
Practice Address - Country:US
Practice Address - Phone:218-770-6527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP1066103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist