Provider Demographics
NPI:1063864171
Name:SPEED, CHARLOTTE (CADC II)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:SPEED
Suffix:
Gender:F
Credentials:CADC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 MIZE ST
Mailing Address - Street 2:
Mailing Address - City:LA FAYETTE
Mailing Address - State:GA
Mailing Address - Zip Code:30728-3346
Mailing Address - Country:US
Mailing Address - Phone:706-538-5580
Mailing Address - Fax:706-638-5445
Practice Address - Street 1:501 MIZE ST
Practice Address - Street 2:
Practice Address - City:LA FAYETTE
Practice Address - State:GA
Practice Address - Zip Code:30728-3346
Practice Address - Country:US
Practice Address - Phone:706-538-5580
Practice Address - Fax:706-638-5445
Is Sole Proprietor?:No
Enumeration Date:2016-07-13
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA674101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)