Provider Demographics
NPI:1326240995
Name:IJEI, CHARLOTTE VIRGINIA (MED)
Entity Type:Individual
Prefix:MRS
First Name:CHARLOTTE
Middle Name:VIRGINIA
Last Name:IJEI
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16762 DEVERONNE CIR
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-1617
Mailing Address - Country:US
Mailing Address - Phone:314-704-5961
Mailing Address - Fax:
Practice Address - Street 1:16762 DEVERONNE CIR
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63005-1617
Practice Address - Country:US
Practice Address - Phone:314-704-5961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO001535101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO498115203Medicaid