MEDICARE: DR. DAVID HERL EDD

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	103TC0700X	Clinical Psychologist	2602	OH
2	103TC0700X	Clinical Psychologist	212	AZ

General Provider Information

NPI Number	:	1245407055
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID HERL EDD

Provider Business Mailing Address
First Line	:	PO BOX 36523
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44735-6523
Country	:	US
Telephone Number	:	330-966-8086
Fax Number	:	330-966-8086

Provider Business Practice Location Address
First Line	:	2677 CLEVELAND AVENUE NW
Second Line	:
City	:	CANTON
State	:	OH
Zip	:	44709-3393
Country	:	US
Telephone Number	:	330-966-8086
Fax Number	:	330-966-8086

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

Provider Enumeration Date	:	05/12/2008
Last Update Date	:	05/15/2008

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Directions to “ DR. DAVID HERL EDD” Practice Location

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