Provider Demographics
NPI:1568917193
Name:HERNDON, MARIETTA (MA,, LGPC)
Entity Type:Individual
Prefix:MRS
First Name:MARIETTA
Middle Name:
Last Name:HERNDON
Suffix:
Gender:F
Credentials:MA,, LGPC
Other - Prefix:MRS
Other - First Name:MARIETTA
Other - Middle Name:ELENA
Other - Last Name:JONES HERNDON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4990 RHODE ISLAND AVE
Mailing Address - Street 2:HYATTSVILLE
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20781-2027
Mailing Address - Country:US
Mailing Address - Phone:301-699-3660
Mailing Address - Fax:
Practice Address - Street 1:4900 RHODE ISLAND AVE STE 101
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20781-2040
Practice Address - Country:US
Practice Address - Phone:301-699-3660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP6887101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDLGP6887OtherLICENSE GRADUATE PROFESSIONAL COUNSELOR