Provider Demographics
NPI:1194768374
Name:HERBER, KATHRYN DELEA (PHD)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:DELEA
Last Name:HERBER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:DELEA
Other - Last Name:BURGTORF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7132 STEWART LN
Mailing Address - Street 2:
Mailing Address - City:BENBROOK
Mailing Address - State:TX
Mailing Address - Zip Code:76126-4611
Mailing Address - Country:US
Mailing Address - Phone:817-798-4324
Mailing Address - Fax:
Practice Address - Street 1:4388 W VICKERY BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-6339
Practice Address - Country:US
Practice Address - Phone:817-798-4324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32212103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX613426Medicare PIN