Basic Information
Provider Information | |||||||||
NPI: | 1790711539 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HERSHBERGER | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | K | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMFT, LMHC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 330 LAKEVIEW DR | ||||||||
Address2: |   | ||||||||
City: | GOSHEN | ||||||||
State: | IN | ||||||||
PostalCode: | 465289365 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5745331234 | ||||||||
FaxNumber: | 5745372652 | ||||||||
Practice Location | |||||||||
Address1: | 2600 OAKLAND AVE | ||||||||
Address2: |   | ||||||||
City: | ELKHART | ||||||||
State: | IN | ||||||||
PostalCode: | 465171533 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5745331234 | ||||||||
FaxNumber: | 5745372652 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/23/2006 | ||||||||
LastUpdateDate: | 08/28/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 39000464A | IN | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X | 35000508A | IN | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 000000204891 | 01 | IN | ANTHEM | OTHER |