Provider Demographics
NPI:1750303475
Name:WASHAM, CHARLES W JR (DMIN, MSW)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:W
Last Name:WASHAM
Suffix:JR
Gender:M
Credentials:DMIN, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2734 CHANCELLOR DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CRESTVIEW HILLS
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3487
Mailing Address - Country:US
Mailing Address - Phone:859-982-9009
Mailing Address - Fax:859-341-3709
Practice Address - Street 1:2734 CHANCELLOR DR
Practice Address - Street 2:SUITE 202
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-3487
Practice Address - Country:US
Practice Address - Phone:859-982-9009
Practice Address - Fax:859-341-3709
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2016-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN340031271041C0700X
KY119106H00000X, 106H00000X
VA0717000269106H00000X, 106H00000X
KY103679101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health