Provider Demographics
NPI:1366855462
Name:CHARLESTON, VICTORIA (LCAC)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:CHARLESTON
Suffix:
Gender:F
Credentials:LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5077 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46408-4628
Mailing Address - Country:US
Mailing Address - Phone:219-887-0510
Mailing Address - Fax:
Practice Address - Street 1:1110 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46402-1723
Practice Address - Country:US
Practice Address - Phone:219-885-4264
Practice Address - Fax:219-239-2944
Is Sole Proprietor?:No
Enumeration Date:2014-06-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87001015A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)