Healthcare Provider Details

I. General information

NPI: 1447812110
Provider Name (Legal Business Name): CHARLES WILLIAM HEMINGWAY NCC, MAC, CADC III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2019
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59939 MINNETONKA CIR
BEND OR
97702-9196
US

IV. Provider business mailing address

1854 NE DIVISION ST
BEND OR
97701-3502
US

V. Phone/Fax

Practice location:
  • Phone: 541-318-1897
  • Fax:
Mailing address:
  • Phone: 541-388-2096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number09-12-70
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier09-12-70
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerSTATE CERTIFIED AOD COUNSELOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: