Provider Demographics
NPI:1235436171
Name:BAILLIEUL, CHARLOTTE (CNP, RN, LICSW)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:
Last Name:BAILLIEUL
Suffix:
Gender:F
Credentials:CNP, RN, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 8TH ST APT 2110
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-4217
Mailing Address - Country:US
Mailing Address - Phone:617-645-5249
Mailing Address - Fax:
Practice Address - Street 1:1125 CENTRE ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130
Practice Address - Country:US
Practice Address - Phone:617-645-5249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-11
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1183961041C0700X
MARN2312255163WP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health