Healthcare Provider Details

I. General information

NPI: 1164026282
Provider Name (Legal Business Name): TIM SCOTT HERZOG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 11/30/2020
Certification Date: 11/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7835 MAIN ST N STE 220
MAPLE GROVE MN
55369-7072
US

IV. Provider business mailing address

4544 3RD ST NE
FRIDLEY MN
55421-2149
US

V. Phone/Fax

Practice location:
  • Phone: 763-400-7475
  • Fax: 763-400-7473
Mailing address:
  • Phone: 651-334-8321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: