Provider Demographics
NPI:1992788491
Name:HERLIHY, CHARLES E JR (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:E
Last Name:HERLIHY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 SYCAMORE CT
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-8259
Mailing Address - Country:US
Mailing Address - Phone:251-490-7527
Mailing Address - Fax:817-442-0204
Practice Address - Street 1:530 SILICON DR
Practice Address - Street 2:SUITE 103
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-9017
Practice Address - Country:US
Practice Address - Phone:817-442-0200
Practice Address - Fax:817-442-0204
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL000080222084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000009927Medicaid