Provider Demographics
NPI:1780974519
Name:HERISSE, WETZLAR
Entity type:Individual
Prefix:MRS
First Name:WETZLAR
Middle Name:
Last Name:HERISSE
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 1:1426 ISLAND SHORES DR
Mailing Address - Street 2:
Mailing Address - City:GREENACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33413-2120
Mailing Address - Country:US
Mailing Address - Phone:561-856-8939
Mailing Address - Fax:
Practice Address - Street 1:1551 FORUM PL
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-2319
Practice Address - Country:US
Practice Address - Phone:561-616-8412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-13
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0000000103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst