Provider Demographics
NPI:1568609956
Name:MATHLIN-SULLY, CHARLENE A (SSP, NCSP)
Entity Type:Individual
Prefix:MS
First Name:CHARLENE
Middle Name:A
Last Name:MATHLIN-SULLY
Suffix:
Gender:F
Credentials:SSP, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1833 HALSTEAD BLVD
Mailing Address - Street 2:APT. 1105
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32309-3460
Mailing Address - Country:US
Mailing Address - Phone:786-877-7934
Mailing Address - Fax:
Practice Address - Street 1:1833 HALSTEAD BLVD
Practice Address - Street 2:APT. 1105
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32309-3460
Practice Address - Country:US
Practice Address - Phone:786-877-7934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS1236103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool