Provider Demographics
NPI:1558665208
Name:BYNUM, CHARLENE WHITE (DOCTORAL STUDENT HCA)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:WHITE
Last Name:BYNUM
Suffix:
Gender:F
Credentials:DOCTORAL STUDENT HCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 ELDORADO HILLS CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89110-5646
Mailing Address - Country:US
Mailing Address - Phone:702-810-4830
Mailing Address - Fax:702-255-7766
Practice Address - Street 1:1213 BALZAR AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-2207
Practice Address - Country:US
Practice Address - Phone:702-810-4830
Practice Address - Fax:702-255-7766
Is Sole Proprietor?:No
Enumeration Date:2011-01-10
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5464TLF-1101YA0400X
NV5061AGC-1103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV251S0000XMedicaid
NV251B00000XMedicare Oscar/Certification