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General NPI Number Information
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NPI Number | 1740165117
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Entity Type | Individual
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Provider Name | MICKAELLA LEE HERRIDGE ATC, MAT, LAT
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Gender | Female
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Dates
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Enumeration Date | 08/06/2025
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Last Update Date | 08/06/2025
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Provider Practice Location Address
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Address Line | 1426 S HOUSTON ST
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City | BULLARD
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State | TX
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Zip | 75757-5555
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Country | US
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Telephone | 903-894-2862
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Fax |
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Provider Business Mailing Address
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Address Line | 17182 PINTAIL DR
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City | FLINT
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State | TX
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Zip | 75762-9610
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Country | US
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Telephone | 701-840-0949
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT9595
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License Number State | TX
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