Basic Information
| Provider Information | |||||||||
| NPI: | 1073625398 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERMANSON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | GLENN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 810 AURORA WAY | ||||||||
| Address2: | |||||||||
| City: | BLYTHE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922251351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609218741 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1297 W HOBSONWAY | ||||||||
| Address2: | |||||||||
| City: | BLYTHE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922251423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609215000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC39211 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.