Provider Demographics
NPI:1184314130
Name:HERBERT, MICHAEL JR (ATC)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:HERBERT
Suffix:JR
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10174 CANNON BALL CT
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-3512
Mailing Address - Country:US
Mailing Address - Phone:571-358-4014
Mailing Address - Fax:
Practice Address - Street 1:1101 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21230-2602
Practice Address - Country:US
Practice Address - Phone:410-324-6141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260033792255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer