Provider Demographics
NPI:1306386727
Name:THEPSIMUONG, CHARLENE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:CHARLENE
Middle Name:
Last Name:THEPSIMUONG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7211 CLOVERDALE RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-8221
Mailing Address - Country:US
Mailing Address - Phone:540-966-5808
Mailing Address - Fax:
Practice Address - Street 1:707 5TH ST NE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-2123
Practice Address - Country:US
Practice Address - Phone:540-819-3622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-04
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040097811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical