Provider Demographics
NPI:1982793337
Name:BURNS, CHARLES J JR (LCSW)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
Last Name:BURNS
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:C.J.
Other - Middle Name:
Other - Last Name:BURNS
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:LICSW
Mailing Address - Street 1:PO BOX 8459
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97207-8459
Mailing Address - Country:US
Mailing Address - Phone:503-238-0769
Mailing Address - Fax:
Practice Address - Street 1:10373 NE HANCOCK ST
Practice Address - Street 2:SUITE 200
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-3873
Practice Address - Country:US
Practice Address - Phone:503-247-5586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000085681041C0700X
ORL42421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8857833Medicare ID - Type Unspecified