Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor |
NPI | 1003277534 |
---|---|
Provider Name | Christine Herzog |
First Address | Victoria, MN 55386-0051 |
Second Address | Victoria, MN 55386-7723 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/03/2016 |
Last Update Date | 07/11/2018 |