Provider Demographics
NPI:1972705234
Name:HERSOM, LYNNE L (LOT)
Entity Type:Individual
Prefix:
First Name:LYNNE
Middle Name:L
Last Name:HERSOM
Suffix:
Gender:F
Credentials:LOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 S. 7TH ST.
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MT
Mailing Address - Zip Code:59840
Mailing Address - Country:US
Mailing Address - Phone:406-363-1390
Mailing Address - Fax:
Practice Address - Street 1:63 MAIN ST
Practice Address - Street 2:
Practice Address - City:STEVENSVILLE
Practice Address - State:MT
Practice Address - Zip Code:59870
Practice Address - Country:US
Practice Address - Phone:406-777-5411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1001225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1001OtherOT LICENSE