Provider Demographics
NPI:1790833853
Name:GROVES DBA LIBERTY COUNSELING, CHARLOTTE LOUISE (LMFT)
Entity Type:Individual
Prefix:MS
First Name:CHARLOTTE
Middle Name:LOUISE
Last Name:GROVES DBA LIBERTY COUNSELING
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 W HURON ST
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:54923-1587
Mailing Address - Country:US
Mailing Address - Phone:920-290-0107
Mailing Address - Fax:920-361-2334
Practice Address - Street 1:141 W HURON ST
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:WI
Practice Address - Zip Code:54923-1587
Practice Address - Country:US
Practice Address - Phone:920-290-0107
Practice Address - Fax:920-361-2334
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI652-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI409-33800Medicaid