Provider Demographics
NPI:1184705428
Name:HERZOG, LAURA MARIE (PSYD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:MARIE
Last Name:HERZOG
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:MRS
Other - First Name:LAURA
Other - Middle Name:HERZOG
Other - Last Name:CHARBONNEAU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:323 W MULBERRY ST
Mailing Address - Street 2:PO BOX 322
Mailing Address - City:WATSEKA
Mailing Address - State:IL
Mailing Address - Zip Code:60970-1568
Mailing Address - Country:US
Mailing Address - Phone:815-432-5241
Mailing Address - Fax:815-432-4537
Practice Address - Street 1:323 W MULBERRY ST
Practice Address - Street 2:
Practice Address - City:WATSEKA
Practice Address - State:IL
Practice Address - Zip Code:60970-1568
Practice Address - Country:US
Practice Address - Phone:815-432-5241
Practice Address - Fax:815-432-4537
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical