Provider Demographics
NPI:1821218157
Name:CHARLTON, ALICE
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:CHARLTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 652
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:AK
Mailing Address - Zip Code:99559-0652
Mailing Address - Country:US
Mailing Address - Phone:907-543-4633
Mailing Address - Fax:
Practice Address - Street 1:970 6TH AVE
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:AK
Practice Address - Zip Code:99559-0652
Practice Address - Country:US
Practice Address - Phone:907-543-4633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-27
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMH0150Medicaid