Provider Demographics
NPI:1114442035
Name:CANADA, CHARLENE L (MRC CRC)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:L
Last Name:CANADA
Suffix:
Gender:F
Credentials:MRC CRC
Other - Prefix:
Other - First Name:CHARLENE
Other - Middle Name:L
Other - Last Name:CANADA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MRC CRC
Mailing Address - Street 1:12591 E COW HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:WY
Mailing Address - Zip Code:82636-9701
Mailing Address - Country:US
Mailing Address - Phone:307-337-6307
Mailing Address - Fax:
Practice Address - Street 1:12591 E COW HOLLOW RD
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82636
Practice Address - Country:US
Practice Address - Phone:307-337-6307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management