Provider Demographics
NPI:1568903615
Name:CHARLES, SHAWNTESE ELICIA (LCSW-C)
Entity Type:Individual
Prefix:
First Name:SHAWNTESE
Middle Name:ELICIA
Last Name:CHARLES
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2904 NEMETH LN
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-1213
Mailing Address - Country:US
Mailing Address - Phone:240-643-3894
Mailing Address - Fax:
Practice Address - Street 1:2904 NEMETH LN
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-1213
Practice Address - Country:US
Practice Address - Phone:240-643-3894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-08
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD158301041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical