Provider Demographics
NPI:1972275006
Name:SIERRA, CHARLES (BACHELORS IN SCIENCE)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:SIERRA
Suffix:
Gender:M
Credentials:BACHELORS IN SCIENCE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7480 DWELL WELL WAY
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-8913
Mailing Address - Country:US
Mailing Address - Phone:786-246-5411
Mailing Address - Fax:
Practice Address - Street 1:7480 DWELL WELL WAY
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-8913
Practice Address - Country:US
Practice Address - Phone:786-246-5411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-28
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling