Provider Demographics
NPI:1194085464
Name:HERRON, CYNTHIA ALISIA
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:ALISIA
Last Name:HERRON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27777 INKSTER RD STE 100
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-5326
Mailing Address - Country:US
Mailing Address - Phone:248-299-0030
Mailing Address - Fax:
Practice Address - Street 1:400 RENAISSANCE CTR STE 2600
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48243-1502
Practice Address - Country:US
Practice Address - Phone:773-639-4983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-21
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
MI7401000983103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other