Provider Demographics
NPI:1447514534
Name:HERGENROEDER, NINOOSH SADEGHI (LMSW)
Entity type:Individual
Prefix:MRS
First Name:NINOOSH
Middle Name:SADEGHI
Last Name:HERGENROEDER
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 HOMESTEAD DR
Mailing Address - Street 2:SUITE G
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-5243
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1320 HOMESTEAD DR
Practice Address - Street 2:SUITE G
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-5243
Practice Address - Country:US
Practice Address - Phone:580-355-8883
Practice Address - Fax:580-355-8885
Is Sole Proprietor?:No
Enumeration Date:2012-07-03
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4257104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker