Provider Demographics
NPI:1508391954
Name:CHARLES, IBSEN
Entity Type:Individual
Prefix:
First Name:IBSEN
Middle Name:
Last Name:CHARLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:IBSEN
Other - Middle Name:
Other - Last Name:VARGAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:196 GREYROCK PL
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06901-2006
Mailing Address - Country:US
Mailing Address - Phone:203-324-6127
Mailing Address - Fax:
Practice Address - Street 1:196 GREYROCK PL
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06901-2006
Practice Address - Country:US
Practice Address - Phone:917-406-4911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-24
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator