Provider Demographics
NPI:1417540121
Name:NEWSOM, CHARLOTTE D (LCPC)
Entity Type:Individual
Prefix:MRS
First Name:CHARLOTTE
Middle Name:D
Last Name:NEWSOM
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19195
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60619-0195
Mailing Address - Country:US
Mailing Address - Phone:773-844-5957
Mailing Address - Fax:
Practice Address - Street 1:7956 S VERNON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-3760
Practice Address - Country:US
Practice Address - Phone:773-844-5957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-12
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL013326101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional