Provider Demographics
NPI:1417333279
Name:HERRERA, JUAN
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:HERRERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 CEDAR SPRING RD.
Mailing Address - Street 2:108
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75235
Mailing Address - Country:US
Mailing Address - Phone:972-863-0749
Mailing Address - Fax:
Practice Address - Street 1:5000 CEDAR SPRING RD.
Practice Address - Street 2:108
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235
Practice Address - Country:US
Practice Address - Phone:972-863-0749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66557101Y00000X, 101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional