Provider Demographics
NPI:1548212392
Name:HERRMANN, MARK A (PHD HSPP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:HERRMANN
Suffix:
Gender:M
Credentials:PHD HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9106 N MERIDIAN ST
Mailing Address - Street 2:STE 100
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1884
Mailing Address - Country:US
Mailing Address - Phone:317-575-9111
Mailing Address - Fax:317-571-4470
Practice Address - Street 1:9106 N MERIDIAN ST
Practice Address - Street 2:STE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1884
Practice Address - Country:US
Practice Address - Phone:317-575-9111
Practice Address - Fax:317-571-4470
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040942A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000374776OtherBCBS