Provider Demographics
NPI:1215035894
Name:SMITH, CHARLES (LPC, LAC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:LPC, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1585 3RD ST
Mailing Address - Street 2:BJACH
Mailing Address - City:FORT POLK
Mailing Address - State:LA
Mailing Address - Zip Code:71459-5102
Mailing Address - Country:US
Mailing Address - Phone:337-531-3755
Mailing Address - Fax:
Practice Address - Street 1:1585 3RD ST
Practice Address - Street 2:BJACH
Practice Address - City:FORT POLK
Practice Address - State:LA
Practice Address - Zip Code:71459-5102
Practice Address - Country:US
Practice Address - Phone:337-531-1972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA641101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA641OtherLAC
LA1863OtherLPC