Provider Demographics
NPI:1831079243
Name:HERRERA, EDITH MICHELLE
Entity type:Individual
Prefix:
First Name:EDITH
Middle Name:MICHELLE
Last Name:HERRERA
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 1:2500 NESCONSET HWY BLDG 22B
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-2598
Mailing Address - Country:US
Mailing Address - Phone:631-751-7988
Mailing Address - Fax:
Practice Address - Street 1:2500 NESCONSET HWY BLDG 22B
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-2598
Practice Address - Country:US
Practice Address - Phone:631-751-7988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-05
Last Update Date:2025-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054903-01225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist