Provider Demographics
NPI:1982190963
Name:TCHEUTCHOUA FOPA, CHARLIE LAURE
Entity Type:Individual
Prefix:
First Name:CHARLIE LAURE
Middle Name:
Last Name:TCHEUTCHOUA FOPA
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 1:11405 PROSPECT CT
Mailing Address - Street 2:
Mailing Address - City:GLENN DALE
Mailing Address - State:MD
Mailing Address - Zip Code:20769-9451
Mailing Address - Country:US
Mailing Address - Phone:240-413-0216
Mailing Address - Fax:
Practice Address - Street 1:11405 PROSPECT CT
Practice Address - Street 2:
Practice Address - City:GLENN DALE
Practice Address - State:MD
Practice Address - Zip Code:20769-9451
Practice Address - Country:US
Practice Address - Phone:240-413-0216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-02
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC104100000X
DCHHA13316374U00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty