Provider Demographics
NPI:1316315773
Name:HERZOG, ALEXIS (OTR/L)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:HERZOG
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:ALEXIS
Other - Middle Name:
Other - Last Name:NIMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:PO BOX 6002
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58206-6002
Mailing Address - Country:US
Mailing Address - Phone:701-780-5000
Mailing Address - Fax:
Practice Address - Street 1:1720 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4940
Practice Address - Country:US
Practice Address - Phone:701-280-4070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-02
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104910225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist