Provider Demographics
NPI:1336622760
Name:HERZOG, PAULA GENE (MS, LPC)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:GENE
Last Name:HERZOG
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6459 W M 72 HWY
Mailing Address - Street 2:
Mailing Address - City:GRAYLING
Mailing Address - State:MI
Mailing Address - Zip Code:49738-8021
Mailing Address - Country:US
Mailing Address - Phone:989-348-2544
Mailing Address - Fax:989-348-7617
Practice Address - Street 1:6459 W M 72 HWY
Practice Address - Street 2:
Practice Address - City:GRAYLING
Practice Address - State:MI
Practice Address - Zip Code:49738-8021
Practice Address - Country:US
Practice Address - Phone:989-348-2544
Practice Address - Fax:989-348-7617
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401014194101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI38-2762492Medicaid