Provider Demographics
NPI:1376094904
Name:CLEMONS, CHARLIE JR (LCAS-A)
Entity Type:Individual
Prefix:MR
First Name:CHARLIE
Middle Name:
Last Name:CLEMONS
Suffix:JR
Gender:M
Credentials:LCAS-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-3761
Mailing Address - Country:US
Mailing Address - Phone:336-259-0272
Mailing Address - Fax:
Practice Address - Street 1:709 E MARKET ST STE 100B
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-3282
Practice Address - Country:US
Practice Address - Phone:336-378-0109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLCAS-20133101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)