Provider Demographics
NPI:1740165117
Name:HERRIDGE, MICKAELLA LEE (ATC, MAT, LAT)
Entity type:Individual
Prefix:
First Name:MICKAELLA
Middle Name:LEE
Last Name:HERRIDGE
Suffix:
Gender:F
Credentials:ATC, MAT, LAT
Other - Prefix:
Other - First Name:MICKAELLA
Other - Middle Name:LEE
Other - Last Name:LANGER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:17182 PINTAIL DR
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:TX
Mailing Address - Zip Code:75762-9610
Mailing Address - Country:US
Mailing Address - Phone:701-840-0949
Mailing Address - Fax:
Practice Address - Street 1:1426 S HOUSTON ST
Practice Address - Street 2:
Practice Address - City:BULLARD
Practice Address - State:TX
Practice Address - Zip Code:75757-5555
Practice Address - Country:US
Practice Address - Phone:903-894-2862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-06
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT95952255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer