Provider Demographics
NPI:1790379337
Name:CHARNOCK, MICHAEL (LPC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:CHARNOCK
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 CONESTOGA RD APT A104
Mailing Address - Street 2:
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-1530
Mailing Address - Country:US
Mailing Address - Phone:240-755-5381
Mailing Address - Fax:
Practice Address - Street 1:1000 CONESTOGA RD APT A104
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-1530
Practice Address - Country:US
Practice Address - Phone:240-755-5381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-24
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC012449101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional