Provider Demographics
NPI:1609213164
Name:RISIEN, CHARLENE BOGLE (LCDC, AAC, CCJP, CSA)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:BOGLE
Last Name:RISIEN
Suffix:
Gender:F
Credentials:LCDC, AAC, CCJP, CSA
Other - Prefix:
Other - First Name:CHARLIE
Other - Middle Name:B
Other - Last Name:RISIEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCDC, AAC, CCJP, CSA
Mailing Address - Street 1:1800 N.E. LOOP 410
Mailing Address - Street 2:#210
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78217
Mailing Address - Country:US
Mailing Address - Phone:210-392-3788
Mailing Address - Fax:
Practice Address - Street 1:1800 N.E. LOOP 410
Practice Address - Street 2:#210
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78217
Practice Address - Country:US
Practice Address - Phone:210-392-3788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-23
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7750101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor