Provider Demographics
NPI:1093835910
Name:DEAN, CHARLES HOWARD (CBA)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:HOWARD
Last Name:DEAN
Suffix:
Gender:M
Credentials:CBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1024 40TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-5228
Mailing Address - Country:US
Mailing Address - Phone:727-821-6932
Mailing Address - Fax:
Practice Address - Street 1:1024 40TH AVE NE
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33703-5228
Practice Address - Country:US
Practice Address - Phone:727-821-6932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251COOOOOX251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services