Provider Demographics
NPI:1477562056
Name:OLLIFF, CHARLES LEE (MED,LPC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:LEE
Last Name:OLLIFF
Suffix:
Gender:M
Credentials:MED,LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77701-3834
Mailing Address - Country:US
Mailing Address - Phone:409-813-1116
Mailing Address - Fax:409-813-1116
Practice Address - Street 1:415 S 11TH ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77701-3834
Practice Address - Country:US
Practice Address - Phone:409-813-1116
Practice Address - Fax:409-813-1116
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15662101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX096045204Medicaid