=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396456588
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JULIA HERZOG MS CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2022
-----------------------------------------------------
Last Update Date | 12/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23023 WESTCHESTER BLVD
-----------------------------------------------------
City | PORT CHARLOTTE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33980-8448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-315-6079
-----------------------------------------------------
Fax | 941-613-0058
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13441 PALAU CIR
-----------------------------------------------------
City | PORT CHARLOTTE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33953-2528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-960-7485
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SA16072
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------