Provider Demographics
NPI:1427390970
Name:ANDERSON, CHARLES IV (LPC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:ANDERSON
Suffix:IV
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 HARTFORD TER
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-0661
Mailing Address - Country:US
Mailing Address - Phone:770-841-1410
Mailing Address - Fax:
Practice Address - Street 1:1445 HARTFORD TER
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30004-0661
Practice Address - Country:US
Practice Address - Phone:770-841-1410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-22
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006090101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional