Provider Demographics
NPI:1265932495
Name:HERETH, CYNTHIA MARIE
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:MARIE
Last Name:HERETH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CYNTHIA
Other - Middle Name:MARIE
Other - Last Name:PEARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9806 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-2234
Mailing Address - Country:US
Mailing Address - Phone:414-543-5330
Mailing Address - Fax:
Practice Address - Street 1:9806 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2234
Practice Address - Country:US
Practice Address - Phone:414-543-5330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2732-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant