Healthcare Provider Details

I. General information

NPI: 1184366940
Provider Name (Legal Business Name): MIRANDA B HERZOG RBT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2022
Last Update Date: 04/12/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5220 6TH STREET FRONTAGE RD E STE 1700
SPRINGFIELD IL
62703-5771
US

IV. Provider business mailing address

5220 6TH STREET FRONTAGE RD E STE 1700
SPRINGFIELD IL
62703-5771
US

V. Phone/Fax

Practice location:
  • Phone: 217-525-8332
  • Fax: 217-789-1420
Mailing address:
  • Phone: 217-525-8332
  • Fax: 217-789-1420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: