Provider Demographics
NPI:1619922952
Name:HERBRICH, MARK ALAN (PT, MA)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:HERBRICH
Suffix:
Gender:M
Credentials:PT, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 BRYANT AVE
Mailing Address - Street 2:
Mailing Address - City:FLORAL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11001-1466
Mailing Address - Country:US
Mailing Address - Phone:516-488-8808
Mailing Address - Fax:516-488-8818
Practice Address - Street 1:1999 MARCUS AVE
Practice Address - Street 2:SUITE M15
Practice Address - City:LAKE SUCCESS
Practice Address - State:NY
Practice Address - Zip Code:11042-1013
Practice Address - Country:US
Practice Address - Phone:516-488-8808
Practice Address - Fax:516-488-8818
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015532-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ4WMJ1Medicare PIN
1619922952Medicare PIN