Provider Demographics
NPI:1851034797
Name:CHARLES, CHARLAINE
Entity Type:Individual
Prefix:
First Name:CHARLAINE
Middle Name:
Last Name:CHARLES
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 1:1719 WILEY ST APT 2
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33020-6572
Mailing Address - Country:US
Mailing Address - Phone:305-794-0729
Mailing Address - Fax:
Practice Address - Street 1:13650 NW 8TH ST STE 109
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33325-6239
Practice Address - Country:US
Practice Address - Phone:866-991-3209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-19
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician