Provider Demographics
NPI:1710916440
Name:CHARLES, NIXON (LCSW)
Entity Type:Individual
Prefix:
First Name:NIXON
Middle Name:
Last Name:CHARLES
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 CHURCH LN
Mailing Address - Street 2:
Mailing Address - City:MIDDLE ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:11953-1708
Mailing Address - Country:US
Mailing Address - Phone:718-826-0350
Mailing Address - Fax:
Practice Address - Street 1:7701 13TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11228-2413
Practice Address - Country:US
Practice Address - Phone:718-232-1351
Practice Address - Fax:718-837-5676
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0590011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P27741Medicare UPIN
NU2481Medicare ID - Type Unspecified