Provider Demographics
NPI:1598243735
Name:ELROD, CHARLIE
Entity Type:Individual
Prefix:
First Name:CHARLIE
Middle Name:
Last Name:ELROD
Suffix:
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 1:211 8TH ST
Mailing Address - Street 2:
Mailing Address - City:PAINTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41240-1284
Mailing Address - Country:US
Mailing Address - Phone:606-209-1548
Mailing Address - Fax:
Practice Address - Street 1:156 N LAKE DR
Practice Address - Street 2:
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-1270
Practice Address - Country:US
Practice Address - Phone:606-506-5077
Practice Address - Fax:606-506-5039
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY273775101YA0400X
KY283695101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)