Provider Demographics
NPI:1821362153
Name:PRINCE, CHARLES DOUGLAS (LPC, ALPS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:DOUGLAS
Last Name:PRINCE
Suffix:
Gender:M
Credentials:LPC, ALPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 PRIVATE ROAD 977
Mailing Address - Street 2:
Mailing Address - City:PEDRO
Mailing Address - State:OH
Mailing Address - Zip Code:45659-8608
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 PRIVATE ROAD 977
Practice Address - Street 2:
Practice Address - City:PEDRO
Practice Address - State:OH
Practice Address - Zip Code:45659-8608
Practice Address - Country:US
Practice Address - Phone:740-534-1386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-05
Last Update Date:2023-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.1801567101Y00000X
WV276481101Y00000X
WV123101YM0800X
WV2158101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0005355002Medicaid