Provider Demographics
NPI:1609033638
Name:WINDOM, CHARLOTTE PATRICIA (MS)
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:PATRICIA
Last Name:WINDOM
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 RUCKER BLVD
Mailing Address - Street 2:
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-2234
Mailing Address - Country:US
Mailing Address - Phone:334-417-0212
Mailing Address - Fax:334-417-0213
Practice Address - Street 1:1311 RUCKER BLVD
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-2234
Practice Address - Country:US
Practice Address - Phone:334-417-0212
Practice Address - Fax:334-417-0213
Is Sole Proprietor?:No
Enumeration Date:2008-05-19
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3621101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51549947OtherBCBS