Provider Demographics
NPI:1609173673
Name:HERDADE, LAWRENCE JOEL (LCSW)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:JOEL
Last Name:HERDADE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2734
Mailing Address - Country:US
Mailing Address - Phone:207-874-8228
Mailing Address - Fax:207-874-8234
Practice Address - Street 1:195 NORTH ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2734
Practice Address - Country:US
Practice Address - Phone:207-874-8228
Practice Address - Fax:207-874-8234
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-28
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC11691041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical