Provider Demographics
NPI:1609442995
Name:HERBERHOLZ, MANDY ANNE
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:ANNE
Last Name:HERBERHOLZ
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 1:1110 COLLEGE DR STE 206
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-1207
Mailing Address - Country:US
Mailing Address - Phone:701-258-2008
Mailing Address - Fax:
Practice Address - Street 1:1110 COLLEGE DR STE 206
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-1207
Practice Address - Country:US
Practice Address - Phone:701-258-2008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-27
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1127-5-15-21-524101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional