Provider Demographics
NPI:1568941326
Name:CHARLES, ANTOINE J (LCAS)
Entity Type:Individual
Prefix:MR
First Name:ANTOINE
Middle Name:J
Last Name:CHARLES
Suffix:
Gender:M
Credentials:LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4731 SEMINOLE CT
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-9432
Mailing Address - Country:US
Mailing Address - Phone:336-782-7640
Mailing Address - Fax:
Practice Address - Street 1:6614 SHALLOWFORD RD STE 250
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:NC
Practice Address - Zip Code:27023-9305
Practice Address - Country:US
Practice Address - Phone:336-945-0137
Practice Address - Fax:336-945-0137
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-11
Last Update Date:2018-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23019101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty