MEDICARE: TIM SCOTT HERZOG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC1900X	Counseling Psychologist		MN

General Provider Information

NPI Number	:	1164026282
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIM SCOTT HERZOG

Provider Business Mailing Address
First Line	:	4544 3RD ST NE
Second Line	:
City	:	FRIDLEY
State	:	MN
Zip	:	55421-2149
Country	:	US
Telephone Number	:	651-334-8321
Fax Number	:

Provider Business Practice Location Address
First Line	:	7835 MAIN ST N STE 220
Second Line	:
City	:	MAPLE GROVE
State	:	MN
Zip	:	55369-7072
Country	:	US
Telephone Number	:	763-400-7475
Fax Number	:	763-400-7473

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2020
Last Update Date	:	11/30/2020

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Directions to “ TIM SCOTT HERZOG ” Practice Location

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