Provider Demographics
NPI:1013683663
Name:HERRIMAN, DECISLAVA PETROVA (ADT2472)
Entity Type:Individual
Prefix:
First Name:DECISLAVA
Middle Name:PETROVA
Last Name:HERRIMAN
Suffix:
Gender:F
Credentials:ADT2472
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25738 BAPTIST CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20659-4522
Mailing Address - Country:US
Mailing Address - Phone:202-515-1797
Mailing Address - Fax:
Practice Address - Street 1:44871 SAINT ANDREWS CHURCH ROAD
Practice Address - Street 2:
Practice Address - City:CALIFORNIA
Practice Address - State:MD
Practice Address - Zip Code:20619
Practice Address - Country:US
Practice Address - Phone:301-997-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDADT2472101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)