Provider Demographics
NPI:1588189765
Name:SMITH, CHARLES RUSSELL JR
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:RUSSELL
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 DUNN RD
Mailing Address - Street 2:
Mailing Address - City:ASHBURNHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01430-3043
Mailing Address - Country:US
Mailing Address - Phone:978-502-9499
Mailing Address - Fax:
Practice Address - Street 1:152 DUNN RD
Practice Address - Street 2:
Practice Address - City:ASHBURNHAM
Practice Address - State:MA
Practice Address - Zip Code:01430-3043
Practice Address - Country:US
Practice Address - Phone:978-502-9499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health