Basic Information
| Provider Information | |||||||||
| NPI: | 1619414869 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERLICH | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 CASTLE DR APT D | ||||||||
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| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212122303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4436802158 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9101 LIBERTY RD | ||||||||
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| City: | RANDALLSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211333521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106557373 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2017 | ||||||||
| LastUpdateDate: | 01/26/2017 | ||||||||
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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 | 222Q00000X | A02441 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
No ID Information.