=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174094825
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GINNY DAWN HERMAN LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2018
-----------------------------------------------------
Last Update Date | 05/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 302 E CHURCH AVE
-----------------------------------------------------
City | BERRYVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72616-4035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-480-2988
-----------------------------------------------------
Fax | 866-402-6464
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 143
-----------------------------------------------------
City | BERRYVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72616-0143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-480-2988
-----------------------------------------------------
Fax | 866-402-6464
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | P1812150
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------