Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XM0800X | Mental Health | 4458 | CA |
NPI | 1558805242 |
---|---|
Provider Name | Theresa Herbert |
First Address | San Bernardino, CA 92415-0647 |
Second Address | San Bernardino, CA 92415-0647 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/12/2016 |
Last Update Date | 16/07/2019 |