Provider Demographics
NPI:1891137527
Name:MCCLINTOCK, CHARLES CHADBOURNE (MSW, LCSWA)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:CHADBOURNE
Last Name:MCCLINTOCK
Suffix:
Gender:M
Credentials:MSW, LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401B CHARLOTTE AVE
Mailing Address - Street 2:
Mailing Address - City:CAROLINA BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28428-5018
Mailing Address - Country:US
Mailing Address - Phone:910-777-9440
Mailing Address - Fax:
Practice Address - Street 1:5013 WRIGHTSVILLE AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-7045
Practice Address - Country:US
Practice Address - Phone:910-796-6868
Practice Address - Fax:910-796-6869
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-23
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1041C0700X
NCP0102391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical