Provider Demographics
NPI:1316423692
Name:HERRERA, MILLIE GEORGANNA (PSYD)
Entity type:Individual
Prefix:
First Name:MILLIE
Middle Name:GEORGANNA
Last Name:HERRERA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 STATE HIGHEAY 104
Mailing Address - Street 2:
Mailing Address - City:IONE
Mailing Address - State:CA
Mailing Address - Zip Code:95640
Mailing Address - Country:US
Mailing Address - Phone:209-274-4911
Mailing Address - Fax:
Practice Address - Street 1:4001 STATE HIGHEAY 104
Practice Address - Street 2:
Practice Address - City:IONE
Practice Address - State:CA
Practice Address - Zip Code:95640
Practice Address - Country:US
Practice Address - Phone:209-274-4911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-19
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TF0200X
CA31316103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic