Provider Demographics
NPI:1942081211
Name:WRIGHT, CHARLIE (MA, LSP)
Entity Type:Individual
Prefix:
First Name:CHARLIE
Middle Name:
Last Name:WRIGHT
Suffix:
Gender:M
Credentials:MA, LSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3345 13TH ST
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80304-2205
Mailing Address - Country:US
Mailing Address - Phone:720-771-9106
Mailing Address - Fax:
Practice Address - Street 1:350 BROADWAY ST STE 205
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80305-3338
Practice Address - Country:US
Practice Address - Phone:720-771-9106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-11
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO115057103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool