Provider Demographics
NPI:1922207794
Name:HERNDON, CHARLES S (LSW)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:S
Last Name:HERNDON
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2704 I ST NE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98002-2411
Mailing Address - Country:US
Mailing Address - Phone:253-833-7444
Mailing Address - Fax:253-735-4111
Practice Address - Street 1:325 W GOWE ST
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-5892
Practice Address - Country:US
Practice Address - Phone:253-520-9350
Practice Address - Fax:253-520-1799
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000055301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB02356Medicare PIN