Provider Demographics
NPI:1689039604
Name:HERSBERGER, JUSTIN (ATC)
Entity Type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:
Last Name:HERSBERGER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 POPLAR DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:IN
Mailing Address - Zip Code:46001-1038
Mailing Address - Country:US
Mailing Address - Phone:765-546-7459
Mailing Address - Fax:
Practice Address - Street 1:473 E GREENVILLE AVE
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:IN
Practice Address - Zip Code:47394-9436
Practice Address - Country:US
Practice Address - Phone:176-558-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-17
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002327A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer