Provider Demographics
NPI:1043383714
Name:PIERCE, CHARLENE MT (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CHARLENE
Middle Name:MT
Last Name:PIERCE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24402 W LOCKPORT ST
Mailing Address - Street 2:STE 224
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-4248
Mailing Address - Country:US
Mailing Address - Phone:708-476-2656
Mailing Address - Fax:
Practice Address - Street 1:24402 W LOCKPORT ST
Practice Address - Street 2:STE 224
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60544-4248
Practice Address - Country:US
Practice Address - Phone:708-476-2656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2017-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071006432103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical