Provider Demographics
NPI:1437503661
Name:HERZOG COLEMAN, CHRISTINE MARIE (ACMHCE)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:MARIE
Last Name:HERZOG COLEMAN
Suffix:
Gender:F
Credentials:ACMHCE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 S SHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-9687
Mailing Address - Country:US
Mailing Address - Phone:801-547-7101
Mailing Address - Fax:
Practice Address - Street 1:1407 N 2000 W
Practice Address - Street 2:SUITE D
Practice Address - City:CLINTON
Practice Address - State:UT
Practice Address - Zip Code:84015-8562
Practice Address - Country:US
Practice Address - Phone:801-855-7999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-13
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9674369-6010101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health