=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952054249
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLENE HERTZBERG LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2022
-----------------------------------------------------
Last Update Date | 12/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1820 E 7TH STE 330
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83404-6400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-497-0685
-----------------------------------------------------
Fax | 208-497-0506
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1990 DEER VALLEY DR
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83401-6811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-757-1665
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 8861848
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------