Provider Demographics
NPI:1093281065
Name:ETTA L. CHARLEBOIS LISW-S LLC
Entity Type:Organization
Organization Name:ETTA L. CHARLEBOIS LISW-S LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:ETTA
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:CHARLEBOIS
Authorized Official - Suffix:
Authorized Official - Credentials:LISW-S
Authorized Official - Phone:937-712-2438
Mailing Address - Street 1:15618 HILLCREST RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT ORAB
Mailing Address - State:OH
Mailing Address - Zip Code:45154-8507
Mailing Address - Country:US
Mailing Address - Phone:937-712-2438
Mailing Address - Fax:
Practice Address - Street 1:15618 HILLCREST RD
Practice Address - Street 2:
Practice Address - City:MOUNT ORAB
Practice Address - State:OH
Practice Address - Zip Code:45154-8507
Practice Address - Country:US
Practice Address - Phone:937-712-2438
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-17
Last Update Date:2020-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty