Provider Demographics
NPI:1669400107
Name:HERZOG, RAYMOND PAUL (MA, LLP)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:PAUL
Last Name:HERZOG
Suffix:
Gender:M
Credentials:MA, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1013 PARCHMENT DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3664
Mailing Address - Country:US
Mailing Address - Phone:616-974-0901
Mailing Address - Fax:616-974-0923
Practice Address - Street 1:1013 PARCHMENT DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3664
Practice Address - Country:US
Practice Address - Phone:616-974-0901
Practice Address - Fax:616-974-0923
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011394103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIBC/BSOtherP10C976540