Provider Demographics
NPI:1922634062
Name:HERMAN, MARY LERAE
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:LERAE
Last Name:HERMAN
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:PO BOX 680
Mailing Address - Street 2:
Mailing Address - City:MOBRIDGE
Mailing Address - State:SD
Mailing Address - Zip Code:57601-0680
Mailing Address - Country:US
Mailing Address - Phone:605-845-7181
Mailing Address - Fax:605-845-5072
Practice Address - Street 1:12451 HWY 1806
Practice Address - Street 2:
Practice Address - City:MOBRIDGE
Practice Address - State:SD
Practice Address - Zip Code:57601
Practice Address - Country:US
Practice Address - Phone:605-845-7181
Practice Address - Fax:605-845-5072
Is Sole Proprietor?:No
Enumeration Date:2020-03-20
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR029350163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)