Healthcare Provider Details

I. General information

NPI: 1578178406
Provider Name (Legal Business Name): MICHELLE HERRERA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2020
Last Update Date: 09/08/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6166 VESPER AVE
VAN NUYS CA
91411-2851
US

IV. Provider business mailing address

18940 STRATHERN ST
RESEDA CA
91335-1150
US

V. Phone/Fax

Practice location:
  • Phone: 818-997-0414
  • Fax: 818-785-3461
Mailing address:
  • Phone: 818-621-2053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: