Provider Demographics
NPI:1659615110
Name:LAPRADE, CHARLES QUINNTIN IV (MS/EDS)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:QUINNTIN
Last Name:LAPRADE
Suffix:IV
Gender:M
Credentials:MS/EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 56197
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32241-6197
Mailing Address - Country:US
Mailing Address - Phone:904-448-1992
Mailing Address - Fax:904-448-8866
Practice Address - Street 1:5991 CHESTER AVE
Practice Address - Street 2:#104
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-2269
Practice Address - Country:US
Practice Address - Phone:904-448-1992
Practice Address - Fax:904-448-8866
Is Sole Proprietor?:No
Enumeration Date:2012-11-21
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH11416101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health