Provider Demographics
NPI:1871622480
Name:HERRICK, ROBYN L
Entity type:Individual
Prefix:
First Name:ROBYN
Middle Name:L
Last Name:HERRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2645 PORTLAND RD NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-0198
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:906 MAIN AVE
Practice Address - Street 2:
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-3816
Practice Address - Country:US
Practice Address - Phone:503-842-8201
Practice Address - Fax:503-815-1870
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORC2355101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR197749Medicaid
OROOOOWCGKJMedicare ID - Type UnspecifiedMENTAL HEALTH