Provider Demographics
NPI:1114490331
Name:WHITE, CHARLIE (T-LMHC)
Entity Type:Individual
Prefix:
First Name:CHARLIE
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:T-LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 5TH ST SE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52401-2128
Mailing Address - Country:US
Mailing Address - Phone:319-398-3943
Mailing Address - Fax:319-355-3577
Practice Address - Street 1:819 5TH ST SE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52401-2128
Practice Address - Country:US
Practice Address - Phone:319-398-3943
Practice Address - Fax:319-355-3577
Is Sole Proprietor?:No
Enumeration Date:2019-01-10
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA081538101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health