Basic Information
| Provider Information | |||||||||
| NPI: | 1558867614 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERZOG | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | JOLEEN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA, LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 413 E 4TH ST | ||||||||
| Address2: | |||||||||
| City: | LITCHFIELD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553552208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202212411 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1125 6TH ST SE | ||||||||
| Address2: | |||||||||
| City: | WILLMAR | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562014675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202354613 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2018 | ||||||||
| LastUpdateDate: | 04/05/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 1776 | MN | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.