Provider Demographics
NPI:1306855853
Name:CHARIS CENTER
Entity Type:Organization
Organization Name:CHARIS CENTER
Other - Org Name:CHARIS CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/BOARD OF DIRECTORS
Authorized Official - Prefix:MR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:STOLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-378-1549
Mailing Address - Street 1:4041 BAHIA VISTA STREET
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34232
Mailing Address - Country:US
Mailing Address - Phone:941-378-1549
Mailing Address - Fax:941-342-1781
Practice Address - Street 1:4041 BAHIA VISTA ST.
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34233
Practice Address - Country:US
Practice Address - Phone:941-378-1549
Practice Address - Fax:940-342-1781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X, 2084P0800X
FL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL26181400OtherCHARISCENTER AETNA GROUP#
26181400OtherAETNA GROUP
26181400OtherAETNA GROUP