Provider Demographics
NPI:1952519050
Name:HERDEMAN, JAMES (PT)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:HERDEMAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 N MAIN ST
Mailing Address - Street 2:APT. C
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53527-9703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3505 LAKE LYNDA DR
Practice Address - Street 2:SUITE 207
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-8324
Practice Address - Country:US
Practice Address - Phone:877-896-3660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3443225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40143700Medicaid