Provider Demographics
NPI:1740393859
Name:CANELLA, CHARLOTTE ANN (MED LCPC)
Entity Type:Individual
Prefix:MRS
First Name:CHARLOTTE
Middle Name:ANN
Last Name:CANELLA
Suffix:
Gender:F
Credentials:MED LCPC
Other - Prefix:
Other - First Name:CHARLOTTE
Other - Middle Name:ANN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCMHC
Mailing Address - Street 1:6966 S CHERRY LEAF DR APT 411
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-5782
Mailing Address - Country:US
Mailing Address - Phone:801-440-6381
Mailing Address - Fax:
Practice Address - Street 1:535 E 4500 S STE 280
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-2929
Practice Address - Country:US
Practice Address - Phone:801-440-6381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2016-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8595304-6004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
81-3612750OtherEIN NUMBER FOR MY BUSINESS CALLED 'CUSTOMIZED COUNSELING SERVICES, LLC'