Provider Demographics
NPI:1568617926
Name:HERZOG, KATHLEEN SUSAN (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:SUSAN
Last Name:HERZOG
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7111 PARK HEIGHTS AVE UNIT 312
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-1664
Mailing Address - Country:US
Mailing Address - Phone:917-941-3768
Mailing Address - Fax:
Practice Address - Street 1:31 WALKER AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21208-4022
Practice Address - Country:US
Practice Address - Phone:410-415-3515
Practice Address - Fax:410-459-9550
Is Sole Proprietor?:No
Enumeration Date:2008-11-25
Last Update Date:2022-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008085-1235Z00000X
MD08552235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist