Provider Demographics
NPI:1053653741
Name:FONDREN, CHARLOTTE (LMSW)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:FONDREN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 HANCOCK STREET
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-4224
Mailing Address - Country:US
Mailing Address - Phone:989-799-3400
Mailing Address - Fax:989-799-0206
Practice Address - Street 1:500 HANCOCK STREET
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-4224
Practice Address - Country:US
Practice Address - Phone:989-799-3400
Practice Address - Fax:989-799-0206
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-21
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801091763104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker