Provider Demographics
NPI:1942415559
Name:SELF, CHARLES BERNARD (EDD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:BERNARD
Last Name:SELF
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 WINBURN LN
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37069-4103
Mailing Address - Country:US
Mailing Address - Phone:615-595-0513
Mailing Address - Fax:615-251-5618
Practice Address - Street 1:1 LIFEWAY PLZ
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37234-0166
Practice Address - Country:US
Practice Address - Phone:615-251-2953
Practice Address - Fax:615-251-5618
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTNLMT#221106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist