Provider Demographics
NPI:1013093392
Name:HERZOG, DEBORAH (MSW)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:HERZOG
Suffix:
Gender:F
Credentials:MSW
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 311
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-0004
Mailing Address - Country:US
Mailing Address - Phone:781-395-1560
Mailing Address - Fax:781-391-5564
Practice Address - Street 1:10 HIGH ST STE 10
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-3848
Practice Address - Country:US
Practice Address - Phone:781-395-1560
Practice Address - Fax:781-391-5564
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-28
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1045721041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1859056Medicaid
MAP05536Medicare ID - Type Unspecified
UX0164Medicare PIN