Provider Demographics
NPI:1003278755
Name:HERMAN, EDWARD CHARLES (LICSW)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:CHARLES
Last Name:HERMAN
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 SE BLUFF LOOP RD.
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584
Mailing Address - Country:US
Mailing Address - Phone:360-580-1054
Mailing Address - Fax:
Practice Address - Street 1:50 SE BLUFF LOOP RD.
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584
Practice Address - Country:US
Practice Address - Phone:360-580-1054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000096741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical