Provider Demographics
NPI:1871657114
Name:PARKS, CHARLOTTE H (MA, MFT)
Entity Type:Individual
Prefix:MS
First Name:CHARLOTTE
Middle Name:H
Last Name:PARKS
Suffix:
Gender:F
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2861 WESTWOOD LN APT 2
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-4144
Mailing Address - Country:US
Mailing Address - Phone:916-481-3616
Mailing Address - Fax:
Practice Address - Street 1:5709 MARCONI AVE
Practice Address - Street 2:SUITE A
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-4472
Practice Address - Country:US
Practice Address - Phone:916-481-2973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFCC 44116106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFCC 44116OtherMFT LICENSE NUMBER