Provider Demographics
NPI:1205882768
Name:HERSTIK, MIRIAM JANICE (PT)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:JANICE
Last Name:HERSTIK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:15 COURTHOUSE SQ
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TN
Practice Address - Zip Code:37347-3531
Practice Address - Country:US
Practice Address - Phone:423-942-8073
Practice Address - Fax:423-942-6660
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3156797OtherBCBST - GROUP NUMBER
TN0446652Medicaid
TN3156797OtherBCBST - GROUP NUMBER