Basic Information
Provider Information
NPI: 1447561642
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: HERDZIK
FirstName: KAREN
MiddleName: MARGARET
NamePrefix:  
NameSuffix:  
Credential: PH.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: LOPEZ
OtherFirstName: KAREN
OtherMiddleName: MARGARET
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType: 1
Mailing Information
Address1: 325 E PIONEER
Address2:  
City: PUYALLUP
State: WA
PostalCode: 983723265
CountryCode: US
TelephoneNumber: 2536978400
FaxNumber: 2536973730
Practice Location
Address1: 325 E PIONEER
Address2:  
City: PUYALLUP
State: WA
PostalCode: 983723265
CountryCode: US
TelephoneNumber: 2536978400
FaxNumber: 2536973730
Other Information
ProviderEnumerationDate: 06/23/2010
LastUpdateDate: 08/25/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
103T00000X  N Behavioral Health & Social Service ProvidersPsychologist 
103TC0700XPY60652236WAY Behavioral Health & Social Service ProvidersPsychologistClinical

ID Information
IDTypeStateIssuerDescription
600131205NC MEDICAID


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