Provider Demographics
NPI:1194368209
Name:HERWITZ, JOHANNA SEMPLE
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:SEMPLE
Last Name:HERWITZ
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 1:1040 PARK AVE # 2J
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-1032
Mailing Address - Country:US
Mailing Address - Phone:212-410-6845
Mailing Address - Fax:212-828-8732
Practice Address - Street 1:750 PARK AVE APT 1C
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4386
Practice Address - Country:US
Practice Address - Phone:212-327-3624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-21
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY16658103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical