Provider Demographics
NPI:1548317274
Name:HERZOG, LAURIE ELIZABETH (LICSW, PHD)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:ELIZABETH
Last Name:HERZOG
Suffix:
Gender:F
Credentials:LICSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01060-3259
Mailing Address - Country:US
Mailing Address - Phone:413-586-7774
Mailing Address - Fax:
Practice Address - Street 1:155 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTHAMPTON
Practice Address - State:MA
Practice Address - Zip Code:01060-3259
Practice Address - Country:US
Practice Address - Phone:413-586-7774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1015410101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health