Provider Demographics
NPI:1629115142
Name:KLINGMAN, CHARLES (MA, LISAC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:KLINGMAN
Suffix:
Gender:M
Credentials:MA, LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9357 E MENDOZA AVE
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-2264
Mailing Address - Country:US
Mailing Address - Phone:602-741-4911
Mailing Address - Fax:
Practice Address - Street 1:9357 E MENDOZA AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85209-2264
Practice Address - Country:US
Practice Address - Phone:602-741-4911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11700101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional