Provider Demographics
NPI:1396382735
Name:HERRICK, BRYAN
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:HERRICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH BALTIMORE
Mailing Address - State:OH
Mailing Address - Zip Code:45872-1332
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 W STATE ST
Practice Address - Street 2:
Practice Address - City:NORTH BALTIMORE
Practice Address - State:OH
Practice Address - Zip Code:45872-1332
Practice Address - Country:US
Practice Address - Phone:833-692-9135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)