Provider Demographics
NPI:1417676008
Name:ASHWORTH, CHARLENE
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:
Last Name:ASHWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1271 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VIDOR
Mailing Address - State:TX
Mailing Address - Zip Code:77662-3740
Mailing Address - Country:US
Mailing Address - Phone:409-673-7570
Mailing Address - Fax:409-769-8914
Practice Address - Street 1:1271 N MAIN ST
Practice Address - Street 2:
Practice Address - City:VIDOR
Practice Address - State:TX
Practice Address - Zip Code:77662-3740
Practice Address - Country:US
Practice Address - Phone:409-673-7570
Practice Address - Fax:409-769-8914
Is Sole Proprietor?:No
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX85189101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional