Provider Demographics
NPI:1417048067
Name:HERZOG, GEORGE HENRY JR (LICSW)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:HENRY
Last Name:HERZOG
Suffix:JR
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 N 33RD AVE
Mailing Address - Street 2:103
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303
Mailing Address - Country:US
Mailing Address - Phone:320-253-3715
Mailing Address - Fax:320-252-2567
Practice Address - Street 1:325 N 33RD AVE
Practice Address - Street 2:103
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303
Practice Address - Country:US
Practice Address - Phone:320-253-3715
Practice Address - Fax:320-252-2567
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN00756104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN861554300Medicaid
MN809000230Medicare PIN