Basic Information
| Provider Information | |||||||||
| NPI: | 1124604764 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERZOG | ||||||||
| FirstName: | KATRINA | ||||||||
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| Credential: | MSW, LSWAIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6400 SOUTHCENTER BLVD FL 1 | ||||||||
| Address2: | |||||||||
| City: | TUKWILA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981882547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2069012041 | ||||||||
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| Practice Location | |||||||||
| Address1: | 600 BROADWAY STE 170 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981225332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063022600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2021 | ||||||||
| LastUpdateDate: | 09/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | SC61040620 | WA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | SC61040620 | 05 | WA | MEDICAID |