Basic Information
| Provider Information | |||||||||
| NPI: | 1194252270 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERRON | ||||||||
| FirstName: | SCOTT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3154 E COON LAKE RD | ||||||||
| Address2: | |||||||||
| City: | HOWELL | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488439537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486026524 | ||||||||
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| Practice Location | |||||||||
| Address1: | 43825 MICHIGAN AVE STE 1 | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481882551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343970078 | ||||||||
| FaxNumber: | 7343972892 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2017 | ||||||||
| LastUpdateDate: | 05/19/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | XYU992853784 | 05 | MI | MEDICAID |