Provider Demographics
NPI:1912102948
Name:HERDMAN, DOROTHY RENE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:DOROTHY
Middle Name:RENE
Last Name:HERDMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:DOROTHY
Other - Middle Name:RENE
Other - Last Name:HERDMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:409 HOLLY ST
Mailing Address - Street 2:
Mailing Address - City:ST SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-1304
Mailing Address - Country:US
Mailing Address - Phone:912-634-1186
Mailing Address - Fax:
Practice Address - Street 1:220 UVALDA ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-4569
Practice Address - Country:US
Practice Address - Phone:912-285-2487
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW002956101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACSW002956OtherSW LICENSE
FLSW1720OtherLICENSE-SOCIALWORK