Provider Demographics
NPI:1285129577
Name:HERMAN, NELLIE ANN
Entity type:Individual
Prefix:
First Name:NELLIE
Middle Name:ANN
Last Name:HERMAN
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 1:55 DODGE RD
Mailing Address - Street 2:
Mailing Address - City:GETZVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14068-1205
Mailing Address - Country:US
Mailing Address - Phone:716-831-2700
Mailing Address - Fax:
Practice Address - Street 1:6520 NIAGARA FALLS BLVD
Practice Address - Street 2:
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14304-1550
Practice Address - Country:US
Practice Address - Phone:716-283-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP03740101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY161163586Medicaid