Provider Demographics
NPI:1710074208
Name:HERTOG, GARY EDWARD (PSYD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:EDWARD
Last Name:HERTOG
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:426 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:RED WING
Mailing Address - State:MN
Mailing Address - Zip Code:55066-2473
Mailing Address - Country:US
Mailing Address - Phone:651-385-6180
Mailing Address - Fax:651-385-6195
Practice Address - Street 1:426 WEST AVE
Practice Address - Street 2:
Practice Address - City:RED WING
Practice Address - State:MN
Practice Address - Zip Code:55066-2473
Practice Address - Country:US
Practice Address - Phone:651-385-6180
Practice Address - Fax:651-385-6195
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3783103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical