Provider Demographics
NPI:1629408547
Name:HERRERA, MANUEL HERRERA
Entity Type:Individual
Prefix:
First Name:MANUEL HERRERA
Middle Name:
Last Name:HERRERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 BILOXI DR APT A
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-2321
Mailing Address - Country:US
Mailing Address - Phone:817-999-3916
Mailing Address - Fax:
Practice Address - Street 1:907 BILOXI DR APT A
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-2321
Practice Address - Country:US
Practice Address - Phone:817-999-3916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-13
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK000000000Medicaid