Provider Demographics
NPI:1710227624
Name:SEABERG, CHARLES RICHARD JR (LCDC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:RICHARD
Last Name:SEABERG
Suffix:JR
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 1:5704 HAVANA DR
Mailing Address - Street 2:
Mailing Address - City:NORTH RICHLAND HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:76180-6120
Mailing Address - Country:US
Mailing Address - Phone:817-929-2936
Mailing Address - Fax:
Practice Address - Street 1:111 NW 24TH ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76164-8544
Practice Address - Country:US
Practice Address - Phone:817-626-6401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-01
Last Update Date:2013-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3251101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)