Provider Demographics
NPI:1942566179
Name:MOAK, CHARLES (CASAC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:MOAK
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11 TALLOW WOOD CT
Mailing Address - Street 2:
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-2806
Mailing Address - Country:US
Mailing Address - Phone:518-369-6962
Mailing Address - Fax:518-952-8287
Practice Address - Street 1:55 ELM ST
Practice Address - Street 2:
Practice Address - City:GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12801-3549
Practice Address - Country:US
Practice Address - Phone:518-793-7273
Practice Address - Fax:518-798-5004
Is Sole Proprietor?:No
Enumeration Date:2012-04-02
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3689101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03008326Medicaid