Provider Demographics
NPI:1942066337
Name:CHARLES, ANTWINE D SR (LPC)
Entity Type:Individual
Prefix:MR
First Name:ANTWINE
Middle Name:D
Last Name:CHARLES
Suffix:SR
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5337 YORKTOWN BLVD STE 4A2
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78413-5361
Mailing Address - Country:US
Mailing Address - Phone:361-833-0076
Mailing Address - Fax:
Practice Address - Street 1:5337 YORKTOWN BLVD STE 4A2
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78413-5361
Practice Address - Country:US
Practice Address - Phone:361-833-0076
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-23
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX89594101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty