Healthcare Provider Details

I. General information

NPI: 1336804145
Provider Name (Legal Business Name): CORY DAVID HERMANN LPCC (MN) LPC (WI)
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2021
Last Update Date: 11/05/2021
Certification Date: 11/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 CENTRAL AVE
RED WING MN
55066-3138
US

IV. Provider business mailing address

PO BOX 544
RED WING MN
55066-0544
US

V. Phone/Fax

Practice location:
  • Phone: 507-513-5552
  • Fax:
Mailing address:
  • Phone: 507-513-5552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCC02156
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: