1396123766 NPI number — MRS. CHARLOTTE JENICE HERON MA PSYCHOLOGY

Table of content: MRS. CHARLOTTE JENICE HERON MA PSYCHOLOGY (NPI 1396123766)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396123766 NPI number — MRS. CHARLOTTE JENICE HERON MA PSYCHOLOGY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HERON
Provider First Name:
CHARLOTTE
Provider Middle Name:
JENICE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MA PSYCHOLOGY
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOGGS-HERON
Provider Other First Name:
CHARLOTTE
Provider Other Middle Name:
JENICE
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
BOGGS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1396123766
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8284 28TH CT NE STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LACEY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98516-7161
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-559-1506
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8284 28TH CT NE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LACEY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98516-7161
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-559-1506
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/18/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  MG60660327 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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