Provider Demographics
NPI:1790082725
Name:CHARLES, JOHN ADRIAN (LCSW, ADC-II)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ADRIAN
Last Name:CHARLES
Suffix:
Gender:M
Credentials:LCSW, ADC-II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2480 LLEWELLYN AVENUE
Mailing Address - Street 2:KIMBROUGH AMBULATORY CARE CENTER
Mailing Address - City:FORT GEORGE G. MEADE
Mailing Address - State:MD
Mailing Address - Zip Code:20755-5800
Mailing Address - Country:US
Mailing Address - Phone:301-677-8441
Mailing Address - Fax:301-677-8176
Practice Address - Street 1:2480 LLEWELLYN AVE
Practice Address - Street 2:
Practice Address - City:FORT GEORGE G MEADE
Practice Address - State:MD
Practice Address - Zip Code:20755-7081
Practice Address - Country:US
Practice Address - Phone:301-677-8441
Practice Address - Fax:301-677-8176
Is Sole Proprietor?:No
Enumeration Date:2011-02-28
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA081256101YA0400X
VA09040074461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDVAD000Medicare UPIN