Provider Demographics
NPI:1053303438
Name:GILDRIE, CHARLES ARTHUR (LCSW)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:ARTHUR
Last Name:GILDRIE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 BOONE RIDGE DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-4998
Mailing Address - Country:US
Mailing Address - Phone:423-282-1480
Mailing Address - Fax:423-928-1353
Practice Address - Street 1:1520 GROVE ST
Practice Address - Street 2:
Practice Address - City:LOUDON
Practice Address - State:TN
Practice Address - Zip Code:37774-1575
Practice Address - Country:US
Practice Address - Phone:423-282-1480
Practice Address - Fax:423-928-1353
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3693905Medicaid
TN0149943OtherBLUE CROSS/BLUE SHIELD
TN0149943OtherBLUE CROSS/BLUE SHIELD