Provider Demographics
NPI:1760661599
Name:TREAKLE, CHARLOTTE MARIE (MED)
Entity Type:Individual
Prefix:MS
First Name:CHARLOTTE
Middle Name:MARIE
Last Name:TREAKLE
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2140 HILLING AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709
Mailing Address - Country:US
Mailing Address - Phone:907-978-9314
Mailing Address - Fax:
Practice Address - Street 1:3101 LATHROP ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701
Practice Address - Country:US
Practice Address - Phone:907-459-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor