Provider Demographics
NPI:1508363094
Name:HERRERA, DANIEL (BA RC)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
Last Name:HERRERA
Suffix:
Gender:M
Credentials:BA RC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-3108
Mailing Address - Country:US
Mailing Address - Phone:340-208-4788
Mailing Address - Fax:
Practice Address - Street 1:335 N MAIN ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-3108
Practice Address - Country:US
Practice Address - Phone:208-478-8340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-10
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID0171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator