Healthcare Provider Details

I. General information

NPI: 1265770523
Provider Name (Legal Business Name): CHARLES HERMANN BOGDAHN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2013
Last Update Date: 01/08/2023
Certification Date: 01/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1419 EAST COLLEGE WAY
MOUNT VERNON WA
98273
US

IV. Provider business mailing address

PO BOX 591
PEPEEKEO HI
96783
US

V. Phone/Fax

Practice location:
  • Phone: 808-688-3376
  • Fax: 808-961-6819
Mailing address:
  • Phone: 808-688-3376
  • Fax: 808-961-6819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number#615
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: