Provider Demographics
NPI:1336284348
Name:CHARLES, TONY
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:
Last Name:CHARLES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10160 BRIAN KELLY WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-5998
Mailing Address - Country:US
Mailing Address - Phone:916-714-9329
Mailing Address - Fax:
Practice Address - Street 1:4730 47TH AVE STE 300
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95824-3946
Practice Address - Country:US
Practice Address - Phone:916-391-6694
Practice Address - Fax:916-391-6726
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor