Provider Demographics
NPI:1669214508
Name:HERZOG, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:HERZOG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 SPRING GARDEN ST APT 3F
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-3860
Mailing Address - Country:US
Mailing Address - Phone:610-220-9191
Mailing Address - Fax:
Practice Address - Street 1:1528 WALNUT ST STE 510
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-3606
Practice Address - Country:US
Practice Address - Phone:267-669-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-11
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
PASW141689104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker