Provider Demographics
NPI:1568553402
Name:CHARLES, RICHARD (LMFT)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:CHARLES
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3608 SW 58TH AVE
Mailing Address - Street 2:
Mailing Address - City:WEST PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33023-6131
Mailing Address - Country:US
Mailing Address - Phone:305-496-7531
Mailing Address - Fax:413-618-3929
Practice Address - Street 1:10031 PINES BLVD STE 248
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-6180
Practice Address - Country:US
Practice Address - Phone:754-229-5912
Practice Address - Fax:413-618-3929
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT2029106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL767474100Medicaid