Provider Demographics
NPI:1720238538
Name:HERZOG, TIMOTHY P (EDD, LCPC, CMPC, BCB)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:P
Last Name:HERZOG
Suffix:
Gender:M
Credentials:EDD, LCPC, CMPC, BCB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2152 RENARD CT
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-6756
Mailing Address - Country:US
Mailing Address - Phone:410-980-2014
Mailing Address - Fax:
Practice Address - Street 1:2018 STADIUM DR
Practice Address - Street 2:SUITE B
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-0706
Practice Address - Country:US
Practice Address - Phone:406-587-3404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-29
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1334101YM0800X
VA0810006445103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health