Healthcare Provider Details

I. General information

NPI: 1992014237
Provider Name (Legal Business Name): MARK KENNETH HERBST MS,CCC/SLP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2010
Last Update Date: 10/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4061 CREEK RD
YOUNGSTOWN NY
14174-9609
US

IV. Provider business mailing address

4061 CREEK RD
YOUNGSTOWN NY
14174-9609
US

V. Phone/Fax

Practice location:
  • Phone: 716-754-8281
  • Fax:
Mailing address:
  • Phone: 716-754-8281
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number007612-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: