Provider Demographics
NPI:1194252270
Name:HERRON, SCOTT
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:HERRON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3154 E COON LAKE RD
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-9537
Mailing Address - Country:US
Mailing Address - Phone:248-602-6524
Mailing Address - Fax:
Practice Address - Street 1:43825 MICHIGAN AVE STE 1
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-2551
Practice Address - Country:US
Practice Address - Phone:734-397-0078
Practice Address - Fax:734-397-2892
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-19
Last Update Date:2017-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIXYU992853784Medicaid