Provider Demographics
NPI:1467216994
Name:CHARLES, JOSIE LYNN (TLLP)
Entity Type:Individual
Prefix:MRS
First Name:JOSIE
Middle Name:LYNN
Last Name:CHARLES
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7159 MELDRUM RD
Mailing Address - Street 2:
Mailing Address - City:IRA
Mailing Address - State:MI
Mailing Address - Zip Code:48023-2429
Mailing Address - Country:US
Mailing Address - Phone:586-804-1207
Mailing Address - Fax:586-286-5834
Practice Address - Street 1:8344 HALL RD STE 209
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:MI
Practice Address - Zip Code:48317-5554
Practice Address - Country:US
Practice Address - Phone:586-286-5870
Practice Address - Fax:586-286-5834
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-06
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI636200902103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI636200902OtherSTATE LICENSE