Provider Demographics
NPI:1184776676
Name:HERBERT, RICHARD SCOTT (MED, EDS)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:SCOTT
Last Name:HERBERT
Suffix:
Gender:M
Credentials:MED, EDS
Other - Prefix:
Other - First Name:R.
Other - Middle Name:SCOTT
Other - Last Name:HERBERT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MED, EDS
Mailing Address - Street 1:808 3RD ST
Mailing Address - Street 2:STE C
Mailing Address - City:NEPTUNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32266-5081
Mailing Address - Country:US
Mailing Address - Phone:904-247-5669
Mailing Address - Fax:904-247-5642
Practice Address - Street 1:808 3RD ST
Practice Address - Street 2:STE C
Practice Address - City:NEPTUNE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32266-5081
Practice Address - Country:US
Practice Address - Phone:904-247-5669
Practice Address - Fax:904-247-5642
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2017-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT0001341106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ3223OtherBCBS OF FL