Provider Demographics
NPI:1770640054
Name:SEARS, CHARLES VINCENT (LMSW)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:VINCENT
Last Name:SEARS
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4239 KENMORE RD
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-3510
Mailing Address - Country:US
Mailing Address - Phone:248-225-7205
Mailing Address - Fax:
Practice Address - Street 1:730 S LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-2522
Practice Address - Country:US
Practice Address - Phone:248-225-7205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801018629104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI227721OtherMHN PRACTITIONER ID#
MI6801018629OtherLMSW