Provider Demographics
NPI:1871043737
Name:HERCHENBACH, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:HERCHENBACH
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 1:2380 LAKE PARK RD APT 805
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40502-6600
Mailing Address - Country:US
Mailing Address - Phone:847-970-8555
Mailing Address - Fax:
Practice Address - Street 1:900 BEASLEY ST STE 120
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-4266
Practice Address - Country:US
Practice Address - Phone:859-254-1035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2520611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY270795565Medicaid