Provider Demographics
NPI:1942645064
Name:CHARLES, LONA
Entity Type:Individual
Prefix:
First Name:LONA
Middle Name:
Last Name:CHARLES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 SW GOODMAN AVE
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-1418
Mailing Address - Country:US
Mailing Address - Phone:561-574-1814
Mailing Address - Fax:
Practice Address - Street 1:2632 SW PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-2845
Practice Address - Country:US
Practice Address - Phone:772-873-8811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-02
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL104100000X, 222Q00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1942645054Medicaid
FLPENDINGMedicaid