Provider Demographics
NPI:1457355273
Name:HERRON, JANICE E (PHD)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:E
Last Name:HERRON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6767 N WICKHAM RD STE 306
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-2025
Mailing Address - Country:US
Mailing Address - Phone:321-751-1925
Mailing Address - Fax:
Practice Address - Street 1:6767 N WICKHAM RD STE 306
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-2025
Practice Address - Country:US
Practice Address - Phone:321-751-1925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03722103TF0000X
FLPY11448103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA
MD588076OtherMAMSI