Provider Demographics
NPI:1386198604
Name:MCKNIGHT, CHARLES (LCDC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:MCKNIGHT
Suffix:
Gender:M
Credentials:LCDC
Other - Prefix:
Other - First Name:CHARLES
Other - Middle Name:
Other - Last Name:MCKNIGHT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCDC
Mailing Address - Street 1:322 MONTAGUE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76905-5110
Mailing Address - Country:US
Mailing Address - Phone:325-224-3481
Mailing Address - Fax:325-224-4923
Practice Address - Street 1:3553 W HOUSTON HARTE EXPY
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76901-2664
Practice Address - Country:US
Practice Address - Phone:325-224-3481
Practice Address - Fax:325-224-4923
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-04
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13489101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)