Provider Demographics
NPI:1568580082
Name:PIERCE, CHARLES
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:PIERCE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:CHIP
Other - Middle Name:
Other - Last Name:PIERCE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:200 E JOPPA RD
Mailing Address - Street 2:SUITE 402
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-3150
Mailing Address - Country:US
Mailing Address - Phone:410-207-1566
Mailing Address - Fax:
Practice Address - Street 1:200 E JOPPA RD
Practice Address - Street 2:SUITE 402
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21286-3150
Practice Address - Country:US
Practice Address - Phone:410-207-1566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC1110101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional