Basic Information
| Provider Information | |||||||||
| NPI: | 1447561642 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERDZIK | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | MARGARET | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LOPEZ | ||||||||
| OtherFirstName: | KAREN | ||||||||
| OtherMiddleName: | MARGARET | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PH.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 160 STREIF RD | ||||||||
| Address2: | |||||||||
| City: | ELMA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140599685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7163932995 | ||||||||
| FaxNumber: | 8557041612 | ||||||||
| Practice Location | |||||||||
| Address1: | 377 MAIN ST UPPR | ||||||||
| Address2: | |||||||||
| City: | EAST AURORA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140521735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7163932995 | ||||||||
| FaxNumber: | 8557041612 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2010 | ||||||||
| LastUpdateDate: | 07/12/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 023755-01 | NY | N | Behavioral Health & Social Service Providers | Psychologist | 103T00000X | Y | Behavioral Health & Social Service Providers | Psychologist | 103TC0700X | PY60652236 | WA | N | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 6001312 | 05 | NC | MEDICAID |