Provider Demographics
NPI:1467678730
Name:HERRBOLD, SUSAN (LPC, NCC)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:HERRBOLD
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6401 WINIFRED DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133-4805
Mailing Address - Country:US
Mailing Address - Phone:817-370-2800
Mailing Address - Fax:
Practice Address - Street 1:6401 WINIFRED DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76133-4805
Practice Address - Country:US
Practice Address - Phone:817-370-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX08916101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional