Provider Demographics
NPI:1962829754
Name:CHARLES, DANTE I
Entity Type:Individual
Prefix:
First Name:DANTE
Middle Name:
Last Name:CHARLES
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4405 MALL BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:UNION CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30291-2044
Mailing Address - Country:US
Mailing Address - Phone:770-969-4309
Mailing Address - Fax:770-969-4170
Practice Address - Street 1:4405 MALL BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:UNION CITY
Practice Address - State:GA
Practice Address - Zip Code:30291-2044
Practice Address - Country:US
Practice Address - Phone:770-969-4309
Practice Address - Fax:770-969-4170
Is Sole Proprietor?:No
Enumeration Date:2014-03-18
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health