Basic Information
| Provider Information | |||||||||
| NPI: | 1730285131 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HERZBERG | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | GARY | ||||||||
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| Credential: | LCSW,QMHP,MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 396 | ||||||||
| Address2: | |||||||||
| City: | CARSON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986100396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094275973 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2415 SE 43RD AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972061600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039632575 | ||||||||
| FaxNumber: | 5038720116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 09/24/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | L3476 | OR | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | LW00007768 | WA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | LCS 13627 | CA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | A021555-6 | 01 | HMSA BC/BS | OTHER |