Provider Demographics
NPI:1619217999
Name:NORTH, CHARLES WYNNE (LCDC)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:WYNNE
Last Name:NORTH
Suffix:
Gender:M
Credentials:LCDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 SAN PEDRO AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-4610
Mailing Address - Country:US
Mailing Address - Phone:210-299-2400
Mailing Address - Fax:210-270-0545
Practice Address - Street 1:702 SAN PEDRO AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-4610
Practice Address - Country:US
Practice Address - Phone:210-299-2400
Practice Address - Fax:210-270-0545
Is Sole Proprietor?:No
Enumeration Date:2013-02-22
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6561101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)