Healthcare Provider Details

I. General information

NPI: 1891028817
Provider Name (Legal Business Name): MICHAEL DAVID HERMAN PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2009
Last Update Date: 06/03/2021
Certification Date: 06/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

633 N ALBANY RD NW
ALBANY OR
97321-1433
US

IV. Provider business mailing address

444 NW ELKS DR
CORVALLIS OR
97330-3745
US

V. Phone/Fax

Practice location:
  • Phone: 541-926-3441
  • Fax:
Mailing address:
  • Phone: 415-754-1150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number2140
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number2140
License Number StateOR
# 4
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number2140
License Number StateOR
# 5
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2140
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: