Provider Demographics
NPI:1306087176
Name:HERZOG, LEE M (MBA, PSYD)
Entity type:Individual
Prefix:DR
First Name:LEE
Middle Name:M
Last Name:HERZOG
Suffix:
Gender:M
Credentials:MBA, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11911 SAN VICENTE BLVD
Mailing Address - Street 2:SUITE 270
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-5086
Mailing Address - Country:US
Mailing Address - Phone:310-712-2501
Mailing Address - Fax:
Practice Address - Street 1:11911 SAN VICENTE BLVD
Practice Address - Street 2:SUITE 270
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-5086
Practice Address - Country:US
Practice Address - Phone:310-712-2501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-09
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 18054102L00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst