Provider Demographics
NPI:1487864039
Name:HUYCK, CHARLES ALEXANDER (LMSW)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:ALEXANDER
Last Name:HUYCK
Suffix:
Gender:M
Credentials:LMSW
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 1337
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87305-1337
Mailing Address - Country:US
Mailing Address - Phone:505-722-1000
Mailing Address - Fax:
Practice Address - Street 1:516 E NIZHONI BLVD
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5748
Practice Address - Country:US
Practice Address - Phone:505-722-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1-01485101YA0400X
MI6801-0706321041C0700X
IA065111041C0700X, 1041C0700X
MI6801070632104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA06511OtherSTATE OF IOWA
NE1124OtherSTATE OF NEBRASKA LICENSE