Provider Demographics
NPI:1659047967
Name:CROUSE, CHARLES (MA, RMHCI, RMFTI)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:CROUSE
Suffix:
Gender:M
Credentials:MA, RMHCI, RMFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11919 WANDSWORTH DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-2612
Mailing Address - Country:US
Mailing Address - Phone:813-344-1671
Mailing Address - Fax:
Practice Address - Street 1:3825 HENDERSON BLVD STE 404
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-5012
Practice Address - Country:US
Practice Address - Phone:813-344-1671
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-17
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH22490101YM0800X
FLIMT8057106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist