Provider Demographics
NPI:1740613322
Name:THOMPSON-SHEALY, CHARLES R (LCSW)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:R
Last Name:THOMPSON-SHEALY
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 1:260 KINGS MALL CT # 251
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-1574
Mailing Address - Country:US
Mailing Address - Phone:646-362-5194
Mailing Address - Fax:646-980-4704
Practice Address - Street 1:260 KINGS MALL CT # 251
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-1574
Practice Address - Country:US
Practice Address - Phone:646-362-5194
Practice Address - Fax:646-980-4704
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-19
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0101YM0800X
NY0878511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health