Healthcare Provider Details

I. General information

NPI: 1871937078
Provider Name (Legal Business Name): JUSTIN I. HERSOM LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2013
Last Update Date: 07/12/2022
Certification Date: 06/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17250 WILSON RIVER HWY
TILLAMOOK OR
97141-9145
US

IV. Provider business mailing address

17250 WILSON RIVER HWY
TILLAMOOK OR
97141-9145
US

V. Phone/Fax

Practice location:
  • Phone: 832-326-8552
  • Fax: 503-842-5035
Mailing address:
  • Phone: 832-326-8552
  • Fax: 503-842-5035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number55202
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number55202
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6051
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: