Provider Demographics
NPI:1447812110
Name:HEMINGWAY, CHARLES WILLIAM (NCC, MAC, CADC III)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:WILLIAM
Last Name:HEMINGWAY
Suffix:
Gender:M
Credentials:NCC, MAC, CADC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1854 NE DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-3502
Mailing Address - Country:US
Mailing Address - Phone:541-388-2096
Mailing Address - Fax:
Practice Address - Street 1:59939 MINNETONKA CIR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-9196
Practice Address - Country:US
Practice Address - Phone:541-318-1897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR09-12-70101YA0400X
OR101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR09-12-70OtherSTATE CERTIFIED AOD COUNSELOR