Provider Demographics
NPI:1568541779
Name:HERZIG, BETH (LAC)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:HERZIG
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 STEVENS AVE
Mailing Address - Street 2:#1
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-2637
Mailing Address - Country:US
Mailing Address - Phone:207-671-6289
Mailing Address - Fax:
Practice Address - Street 1:500 FOREST AVE
Practice Address - Street 2:SUITE 2A
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-1541
Practice Address - Country:US
Practice Address - Phone:207-775-2059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAC238171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME079159OtherANTHEM PIN #