Provider Demographics
NPI:1730285131
Name:HERZBERG, STEVEN GARY (LCSW,QMHP,MSW)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:GARY
Last Name:HERZBERG
Suffix:
Gender:M
Credentials:LCSW,QMHP,MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 396
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:WA
Mailing Address - Zip Code:98610-0396
Mailing Address - Country:US
Mailing Address - Phone:509-427-5973
Mailing Address - Fax:
Practice Address - Street 1:2415 SE 43RD AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-1600
Practice Address - Country:US
Practice Address - Phone:503-963-2575
Practice Address - Fax:503-872-0116
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORL34761041C0700X
WALW000077681041C0700X
CALCS 136271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
A021555-6OtherHMSA BC/BS
130003Medicare ID - Type Unspecified
A021555-6OtherHMSA BC/BS
P61082Medicare UPIN