Provider Demographics
NPI:1619567104
Name:HERNDON, PATSY
Entity Type:Individual
Prefix:
First Name:PATSY
Middle Name:
Last Name:HERNDON
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 1:63 OLD MILL RD
Mailing Address - Street 2:
Mailing Address - City:PORT WENTWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:31407-6003
Mailing Address - Country:US
Mailing Address - Phone:313-410-9692
Mailing Address - Fax:
Practice Address - Street 1:63 OLD MILL RD
Practice Address - Street 2:
Practice Address - City:PORT WENTWORTH
Practice Address - State:GA
Practice Address - Zip Code:31407-6003
Practice Address - Country:US
Practice Address - Phone:313-410-9692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-19
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC009234101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional