Provider Demographics
NPI:1376631655
Name:CHULACK, CHARLES J (LCSW)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
Last Name:CHULACK
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4655 WILLIAM FLYNN HWY
Mailing Address - Street 2:SUITE 125B
Mailing Address - City:ALLISON PARK
Mailing Address - State:PA
Mailing Address - Zip Code:15101-2243
Mailing Address - Country:US
Mailing Address - Phone:412-492-8585
Mailing Address - Fax:412-492-7882
Practice Address - Street 1:4655 WILLIAM FLYNN HWY
Practice Address - Street 2:SUITE 125B
Practice Address - City:ALLISON PARK
Practice Address - State:PA
Practice Address - Zip Code:15101-2243
Practice Address - Country:US
Practice Address - Phone:412-492-8585
Practice Address - Fax:412-492-7882
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW014647104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA489398OtherVALUE OPTIONS PROVIDER NU
410991OtherUPMC
1591341OtherHIGHMARK BCBS