Provider Demographics
NPI:1548615271
Name:HERSON, MISTY
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:HERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3387 OKEMOS RD
Mailing Address - Street 2:STE. A1
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864
Mailing Address - Country:US
Mailing Address - Phone:517-992-5333
Mailing Address - Fax:
Practice Address - Street 1:3387 OKEMOS RD
Practice Address - Street 2:STE. A1
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864
Practice Address - Country:US
Practice Address - Phone:517-992-5333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-02
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst