Provider Demographics
NPI:1447561642
Name:HERDZIK, KAREN MARGARET (PHD)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:MARGARET
Last Name:HERDZIK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:MARGARET
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:160 STREIF RD
Mailing Address - Street 2:
Mailing Address - City:ELMA
Mailing Address - State:NY
Mailing Address - Zip Code:14059-9685
Mailing Address - Country:US
Mailing Address - Phone:716-393-2995
Mailing Address - Fax:855-704-1612
Practice Address - Street 1:377 MAIN ST UPPR
Practice Address - Street 2:
Practice Address - City:EAST AURORA
Practice Address - State:NY
Practice Address - Zip Code:14052-1735
Practice Address - Country:US
Practice Address - Phone:716-393-2995
Practice Address - Fax:855-704-1612
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023755-01103T00000X
103T00000X
WAPY60652236103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6001312Medicaid