Provider Demographics
NPI:1679167068
Name:HERZBERG, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HERZBERG
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 1:1148 BROADWAY STE 100
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-3518
Mailing Address - Country:US
Mailing Address - Phone:253-597-4550
Mailing Address - Fax:
Practice Address - Street 1:1148 BROADWAY STE 100
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-3518
Practice Address - Country:US
Practice Address - Phone:253-597-4550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-25
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60585400101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health